Every finding on record at Eastland Subacute and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure seven of 63 resident rooms (Rooms 114, 115, 116, 117, 119, 121, and 123) met the square footage requirement of 80 square feet (sq. ft. - unit of measurement) per resident in multiple resident rooms. In addition, the residents who occupied Rooms 114, 115, 116, 117, 119, 121, and 123 from the last recertification survey with exit date of 7/25/2025 were not the same residents who occupied Rooms 114, 115, 116, 117, 119, 121, and 123 during this current recertification survey from 8/25/2026 to 8/28/2026. This deficient practice had the potential for the residents not to have enough space for activities of daily living (ADL- routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves) and hinder staff from providing nursing care to the residents. Findings: During a review of the facility's room waiver request letter dated 8/25/2026, the room waiver request letter indicated the facility was requesting for a room waiver regarding room size for the following rooms: Room Sq. ft. Beds114 300 4115 300 4116 300 4117 300 4 119 300 4121 300 4123 159 2 The room waiver request letter indicated there was reasonable privacy, closet and storage space provided in each room. The room waiver request letter further indicated there was sufficient room to provide nursing care and resident equipment and the rooms are in accordance with the special needs of all residents as necessary. During an interview with the facility Administrator (ADM) on 8/25/2026 at 9:34 am, the ADM stated the facility requested a room waiver this year (2026) for Rooms 114, 115, 116, 117, 119, 121, and 123. The ADM stated nothing had changed, including the number of bed occupancy in the rooms. During the recertification survey conducted from 8/25/2026 to 8/28/2026, Rooms 114, 115, 116, 117, 119, 121, and 123 were observed with adequate space and nursing care and privacy were provided to the residents. The residents were observed to have enough space to move freely inside the rooms. There was adequate room for the operation and use of wheelchairs (chair with wheels), walkers (a device that gave additional support to maintain balance or stability while walking), and Hoyer lift (a mechanical device used to lift and/or transfer a person from place to place). Each resident inside the affected rooms had beds and bedside tables with drawers. The room size did not affect the care and services provided by the staff to the residents when staff were observed providing care to the residents. During an interview with Resident 75 on 8/25/2026 at 11:06 am, in Resident 75's room (room [ROOM NUMBER]), Resident 75 was sitting in a wheelchair. Resident 75 stated Resident 75 had enough space in room [ROOM NUMBER] to move around with no concerns. During an interview with Certified Nurse Assistant 3 (CNA 3) on 8/25/2026 at 10:22 am, CNA 3 stated CNA 3 had enough space to move around in the rooms with four beds to provide resident care. CNA 3 stated CNA 3 was able to move the shower chairs and wheelchairs around when providing resident care in the rooms with four beds. During an interview with the facility's ADM on 8/28/2026 at 11:49 am, the ADM stated the ADM did not know the facility needed to request a new room waiver when there was a change of residents occupying in the rooms previously requested for room waiver. The ADM stated, since the last recertification survey on 7/25/2025, the facility did not apply a new room waiver when there was a change of residents occupying the rooms with room waiver. During a review of the facility's Resident Census from the last recertification survey with exit date of 7/25/2025, the residents who occupied Rooms 114, 115, 116, 117, 119, 121, and 123 were not the same residents who occupied Rooms 114, 115, 116, 117, 119, 121, and 123 during this current recertification survey from 8/25/2026 to 8/28/2026.

Based on observation, interview, and record review, the facility failed to implement infection prevention and control practices by failing to: a. Ensure one of three sampled residents' foley catheter (a flexible plastic tube inserted into the bladder to drain urine outside of the body) bag and tubing were not touching the floor (Resident 111). b. Label and properly stored personal care items consisting of a toothbrush and a bottle of mouthwash that were found inside Rooms A and B's shared bathroom. These failures had the potential to result in cross contamination (the process by which germs are unintentionally transferred from one area/object to another with a harmful effect) and/or the development of infection to Resident 111 and other residents in the facility. Findings: a. During a review of Resident 111's Face Sheet (FS), the FS indicated the facility admitted Resident 111 on 5/3/2022 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), neuromuscular dysfunction of the bladder (when a nerve or muscle problem prevented the bladder from working properly), and retention of urine (the bladder was full but the person could not completely empty it). During a review of Resident 111's Minimum Data Set (MDS, a resident assessment tool) dated 7/23/2026, the MDS indicated Resident 111 had severely impaired cognition (ability to understand) for daily decision making. The MDS indicated Resident 111 was dependent (helper did all the effort) on staff with eating, oral/toileting hygiene, showering/ bathing, personal hygiene, and bed-to-chair transferring. During a review of Resident 111's Order Summary Report (OSR), the OSR indicated an order for staff to provide FC care every shift, starting on 8/7/2026. During a review of Resident 111's Care Plan (CP) for FC revised on 8/18/2026, the CP goal indicated to reduce the risk of infection to Resident 111 daily. The CP indicated a nursing intervention to provide FC care every shift as ordered. During an observation on 8/25/2026 at 10:26 am at Resident 111's bedside, Resident 111's FC drainage bag was touching the floor. During an observation on 8/25/2026 at 2:21 pm at Resident 111's bedside, Resident 111's FC drainage bag and tubing were touching the floor. During a concurrent pictures review and interview with the facility's Director of Nursing (DON) on 8/27/2026 at 3:27 pm, the pictures dated 8/25/2026 at 10:26 am and 2:21 pm were reviewed. The DON stated that the pictures indicated the FC drainage bag and tubing were touching the floor. The DON stated the FC drainage bag and tubing should not be touching the floor for infection control. During a review of the facility's Policy &Procedure (P&P) titled, Catheter Care, Urinary revised 8/2022, the P&P indicated the facility should prevent complications associated with urinary catheter including urinary tract infection (UTI, an infection in the bladder/urinary tract). The P&P indicated the facility should ensure the catheter tubing and drainage bag were kept off the floor. b. During an observation on 8/25/2026 at 10:06 am inside the shared bathroom between Rooms A and B, an unlabeled toothbrush and unlabeled bottle of mouthwash were found on top of the soap dispenser located next to the bathroom sink. During a concurrent observation and interview on 8/25/2026 at 10:10 am with LVN 3 inside the shared bathroom between Rooms A and B, LVN 3 stated personal care items such as toothbrushes and mouthwash were supposed to be labeled with the resident's name and room number. LVN 3 stated personal care items should be kept in a sealable bag and stored inside the resident's bedside drawer to avoid other residents accidentally using the items. LVN 3 stated the toothbrush and mouth wash that were found in the shared bathroom of Rooms A and B belonged to one of the residents in Room A, but LVN 3 was unsure which resident owned the toothbrush and mouth wash. LVN 3 stated a resident in Room B also used the shared bathroom where the toothbrush and mouthwash were found. LVN 3 stated the purpose of properly labeling and storing personal care items was for infection control. During an interview on 8/28/2026 at 9:15 am with the Director of Nursing (DON), the DON stated some bathrooms in the facility were shared between two rooms and by multiple residents. The DON stated personal care items such as toothbrushes, mouthwashes, and razors should be individualized and labeled for identification. The DON stated personal care items should also be kept at bedside to avoid any mix-up with a resident using someone else's personal care items. The DON stated if an unlabeled toothbrush and bottle of mouthwash were found in a shared bathroom, those items should be thrown away to avoid the possible spread of infection. During a review of the facility's Policy and Procedure (P&P) titled, Policies and Practices – Infection Control, revised 10/2018, the P&P indicated the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The P&P further indicated infection control policies and practices are to prevent, detect, investigate, and control infections in the facility.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 6) received care consistent with professional standards of practice to prevent pressure ulcer/injury (damage to the skin and/or underlying tissue caused by pressure on bony areas of the body) when it failed to accurately set Resident 6's low air loss mattress (LALM - a mattress used to prevent and treat pressure injuries by circulating air and relieving pressure on the body) according to Resident 6's weight. This deficient practice had the potential for the development and/or worsening of pressure injuries to Resident 6. Findings: During a review of Resident 6's admission Record (AR), the AR indicated Resident 6 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including stage 3 pressure ulcers (level of impairment where there is full thickness skin loss that may extend into the body's fatty tissue layer) of the sacral region (tailbone), right buttock, and left buttock. The AR further indicated Resident 6 was diagnosed with type 2 diabetes (when the body does not use or produce insulin [hormone] properly, which can lead to delayed wound healing) and Alzheimer's disease (a progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks). During a review of Resident 6's Order Summary Report (OSR) dated 5/27/2026, the OSR indicated the nursing staff may apply a LALM for Resident 6's wound management. The OSR also indicated that the nursing staff was to check the LALM machine function and placement during every shift. During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool) dated 5/30/2026, the MDS indicated Resident 6's cognitive skills (mental ability) for daily decision making was severely impaired. The MDS indicated Resident 6 was dependent (a helper does all of the effort of the activity) for eating, toileting hygiene, and upper/lower body dressing. During a review of Resident 6's Interdisciplinary Weight Management Care Plan (WMC), dated 8/7/2026, the WMC indicated Resident 6's most recent documented weight was 120 pounds on 8/3/2026. During an observation on 8/25/2026 at 11:18 am inside Resident 6's room, Resident 6 was lying in bed with eyes closed. The LALM machine was observed to be set at 450 pounds. During a concurrent observation and interview on 8/25/2026 at 11:24 am with Registered Nurse (RN 3) at Resident 6's bedside, RN 3 stated the purpose of a LALM was to prevent pressure ulcers, especially on residents who were bedridden (when person is unable to get out of bed due to illness, injury, or old age). RN 3 stated the LALM setting was based on a resident's weight. RN 3 stated Resident 6's LALM machine was set at 450 pounds, which is inaccurate because Resident 6 does not weigh 450 pounds. During an interview on 8/28/2026 at 8:58 am with Licensed Vocational Nurse (LVN) 3, LVN 3 stated a LALM was used to prevent and treat pressure ulcers by redistributing (re-arranging) the pressure on a resident's body when lying down in bed. LVN 3 stated only licensed nurses were authorized to handle the LALM machine settings. LVN 3 stated licensed nurses were also responsible for ensuring the LALM were correctly set based on a resident's weight. LVN 3 stated if a certified nursing assistant saw that a LALM setting was incorrect, the nursing assistant was supposed to report it to a licensed nurse to address. LVN 3 stated if a LALM was incorrectly set too high, the mattress would be too firm and would not properly redistribute pressure to a resident's body. LVN 3 stated Resident 6 was usually bedridden and had contractures (tightening or shortening of muscles, tendons, ligaments, or skin) on both legs. LVN 3 stated a LALM was very important for Resident 6 because Resident 6 had a history of having multiple pressure ulcers in the past. During an interview on 8/28/2026 at 9:06 am with Certified Nursing Assistant (CNA 4), CNA 4 stated Resident 6 was oriented (aware) only to Resident 6's name. CNA 4 stated Resident 6 was mostly unable to communicate Resident 6's needs and did not follow commands (when nursing staff gives a resident instructions/directions). CNA 4 stated the facility used stickers in the shape of an arrow on LALM machines to point at the correct setting. CNA 4 stated if a nursing assistant observed that a LALM setting was incorrect, the assistant was supposed to notify a charge nurse or supervisor to fix. During an interview on 8/28/2026 at 9:15 am with the Director of Nursing (DON), the DON stated the purpose of a LALM was to prevent and treat pressure ulcers. The DON stated licensed nurses were responsible for setting LALM based on a resident's weight. The DON stated certified nursing assistants were not permitted to touch the LALM settings, however they should notify the licensed nurses if the LALM settings were observed to be incorrect. The DON further stated that if the LALM setting is incorrectly set too high or too low, then the ordered treatment was not being given to a resident because the LALM was not being used effectively. During a review of the facility's Policy and Procedure (P&P) titled, Policy: Pressure-Reducing Mattresses, revised 6/2026, the P&P indicated to [follow the manufacturer's instruction and adjust low air loss mattress to a desired firmness based on either the resident's weight or comfort.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 128) who was discharged home under the care of home health service (wide range of health care services that could be given at home) had the home health service accurately coded in the Minimum Data Set (MDS, a resident assessment tool) assessment dated [DATE]. This deficient practice resulted in inaccurate reporting to the Centers of Medicare and Medicaid (CMS, a federal agency that administers the Medicare program to administer the Medicaid and health insurance portability standards) agency and had the potential to result in Resident 128 not receiving interventions to address specific care concerns. Findings: During a review of Resident 128's Face Sheet (FS), the FS indicated the facility admitted Resident 128 on 6/11/2026 with diagnoses including End-Stage Renal Disease (ESRD- kidneys cease functioning on a permanent basis), dependence on renal dialysis (removes unwanted toxins, waste products and excess fluids by filtering the blood) and difficulty in walking. During a review of Resident 128's Order Summary Report (OSR) dated 7/9/2026, the OSR indicated to discharge Resident 128 to home under home health and provide durable medical equipment (DME, medically necessary devices prescribed by a physician). During a review of Resident 128's MDS dated [DATE], the MDS indicated Resident 128 was discharged to home/community. During a review of Resident 128's Discharge Summary Report, dated 7/9/2026, the Discharge Summary Report indicated the facility had arranged to discharge Resident 128 to home with Home Heath, and Physical Therapy (PT)/Occupational Therapy (OT) with DME. During a concurrent interview on 8/27/2026 at 2:44 pm with the Minimum Data Set Nurse (MDSN) and record review of Resident 128's MDS dated [DATE], the MDSN stated Resident 128 was discharged to home under home health on 7/9/2026. The MDSN stated Resident 128 was coded discharged to home only and not coded with discharged to home with organized home health in the MDS dated [DATE]. The MDSN stated Resident 128 needed to be coded accurately in the MDS to provide correct information to CMS. During an interview on 8/27/2026 at 3:36 pm with the Director of Nursing (IDON), the DON stated Resident 128 was discharged to home under home health on 7/9/2026 and should have been coded in the MDS dated [DATE] as discharged to home under care of organized home health service organization to give accurate information to CMS. During a review of the facility's Policy and Procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, revised 11/2019, the P&P indicated, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment). During a review of the facility's P&P titled, Resident Assessments revised 3/2022, the P&P indicated, The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: (7) Discharge Assessment (return anticipated and return not anticipated).

Based on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Peripheral and Midline IV (intravenous, medicine or fluid that went straight into a vein) Dressing Changes, by failing to label the IV dressing for one of one sampled resident (Resident 31). This deficient practice had the potential to increase the risk of infection for Resident 31 due to unchanged contaminated IV dressing and could lead to serious medical complications. Findings: During a review of Resident 31's Face Sheet (FS), the FS indicated the facility initially admitted Resident 31 on 2/29/2024 and readmitted on [DATE] with diagnoses including urinary tract infection (UTI, an infection in the bladder/urinary tract [part of the body that carried urine]) and dementia (a progressive state of decline in mental abilities). During a review of Resident 31's Minimum Data Set (MDS, a resident assessment tool) dated 8/7/2026, the MDS indicated Resident 31 required moderate assistance (helper did less than half the effort) from staff with eating, oral hygiene, toileting hygiene, showering/ bathing, personal hygiene, and bed-to-chair transferring. During a review of Resident 31's Order Summary Report (OSR), the OSR indicated staff to check IV site for signs and symptoms of complication and adverse reaction (unwanted, uncomfortable, or dangerous reaction) every shift, starting on 8/22/2026. The OSR indicated staff to provide IV site care every 72 hours, starting on 8/23/2026. The OSR indicated Resident 31 had an active physician order to receive IV medication Ertrapenem (medication to treat bacterial infection) 1 gram (g-metric unit of measurement, used for medication dosage and/or amount) daily for eight days, starting on 8/23/2026. During a review of Resident 31's History and Physical (H&P) dated 8/23/2026, the H&P indicated Resident 31 did not have the capacity to understand and make decisions. The H&P indicated Resident 31 was alert and oriented X 4 (fully aware of self, location, time, and the situation). During a review of Resident 31's care plan (CP) for IV therapy revised on 8/25/2026, the CP goal indicated the IV access would be maintained and free of complication. The CP indicated a nursing intervention for the registered nurse to observe the IV site frequently for signs and symptoms of complications such as redness, swelling, pain, drainage, and leakage. During an observation and interview with Resident 31 on 8/25/2026 at 11:45 am, in the facility's Station 2 Activity Room with Registered Nurse Supervisor 1 (RN 1)'s presence, Resident 31's left forearm IV dressing had dry blood at the insertion site. There was no date or nurse's initial labeled on Resident 31's left forearm IV dressing. Resident 31 stated the IV site was painful. During an interview on 8/25/2026 at 11:45 am with Registered Nurse (RN) 1, RN 1 stated Resident 31's left forearm IV site had dry blood, and there was no date on the IV dressing. RN 1 stated RN 1 should change Resident 31's IV dressing because of the dry blood at the IV site. RN 1 stated the IV dressing should have a date so the nurse would know when to change the IV dressing per physician's order to prevent infection. During a concurrent record review and interview with the facility's Director of Nursing (DON) on 8/27/2026 at 3:13 pm, Resident 31's 8/2026 IV Medication Administration Record (MAR) was reviewed. The DON stated Resident 31's 8/2026 IV MAR indicated RN 2 changed Resident 31's IV dressing and assessed the IV site on 8/23/2026 at 9:24 am. The DON stated the IV dressing should have date and the nurse's initial labeled. The DON stated that registered nurse should assess residents' IV site and possibly change the IV dressing when the resident verbalized pain at the IV site. The DON stated registered nurses should change the IV dressing every 72 hours, and as needed when the IV site had redness and dry blood. The DON stated it was the standard of practice to label the IV dressing with date for the nurses' awareness. The DON stated certified nurse assistants and licensed vocational nurses could check residents' IV site and report to the RN for any abnormalities. The DON stated the risk was infection at the IV site. During a review of the facility's P&P titled, Peripheral and Midline Dressing Changes, revised in 3/2022, the P&P indicated the facility should prevent complications associated with IV therapy including contaminated or soiled IV dressing. The P&P indicated the facility should maintain sterile dressing for all IV sites. The P&P further indicated the staff should label the IV dressing with date and time of dressing change, and the initials.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 73) receiving oxygen therapy was provided respiratory care and resident safety in accordance with the facility's Policy and Procedure (P&P) titled Oxygen Administration and professional standards of practice. This deficient practice had the potential to increase the risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) for Resident 73, which could result in serious respiratory complications. Findings: During a review of Resident 73's Face Sheet (FS), the FS indicated the facility admitted Resident 73 on 3/4/2024 and readmitted on [DATE] with diagnoses including encounter for attention to tracheostomy (surgical opening in the throat in which a tube is placed for the resident's breathing) and chronic respiratory failure (a condition when the lungs cannot get enough oxygen into the blood). During a review of Resident 73's untitled Care Plan (CP) initiated on 7/23/2025, the CP indicated Resident 73 was receiving oxygen therapy due to respiratory failure. The CP interventions indicated for nursing staff to check for proper fit of Resident 73's cannula (tube which on one end splits into two prongs which are placed in the nostrils to deliver oxygen) or mask and to provide oxygen as ordered. During a review of Resident 73's Order Summary Report (OSR) dated 9/23/2025, the OSR indicated to administer oxygen to Resident 73 at two (2) liters per minute (L/min) via (through) nasal cannula, may titrate up to five (5) L/min for oxygen saturation (measure of how much oxygen the blood is carrying) less than 92 percent (%) every shift. During a review of Resident 73's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/11/2026, the MDS indicated Resident 73 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 73 was dependent (helper does all of the effort) from staff for oral/toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a concurrent observation and interview on 8/25/2026 at 9:58 am inside Resident 73's room together with Infection Prevention Nurse (IPN), Resident 73 was awake, lying in bed with the oxygen concentrator (a medical device that concentrates oxygen from environmental air and delivers it to the resident in need of supplemental oxygen) on and running at 2LPM via nasal cannula. Resident 73's nasal cannula prongs were resting on the left side of Resident 73's face rather than in Resident 73's nostrils (opening of the nose). The IPN stated the nasal cannula prongs should be placed in Resident 73's nostrils to ensure the resident received oxygen as ordered by the physician. The IPN stated improper oxygen administration could lead to desaturation (low oxygen saturation level) and shortness of breath (SOB). During an interview on 8/27/2026 at 3:41 pm, with the facility's Director of Nursing (DON), the DON stated nasal cannula prongs should be inside the nostrils of Resident 73 to get the adequate amount of oxygen as ordered by the physician. The DON stated if nasal prongs were not properly placed in Resident 73 nostrils, it could cause SOB. During a review of the facility's P&P titled, Oxygen Administration, revised 10/2010, the P&P indicated, The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head. The P&P further indicated to place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter).

Based on observation, interview, and record review, the facility failed to provide the required assistance during activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) for one of two sampled residents (Resident 17). This failure placed Resident 17 at risk of accidents/injury during bed mobility and overall decline in quality of life. Findings: During a review of Resident 17's Face Sheet (FS), the FS indicated the facility admitted Resident 17 on 9/16/2022 with diagnoses including down syndrome (natural genetic [present from birth] condition affecting physical development, learning and overall health), muscle spasm (a sudden, involuntary contraction of one or more muscles), and contracture (a stiffening/shortening at any joint) of the right and left knee. During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool) dated 8/15/2026, the MDS indicated Resident 17 had moderately impaired cognition (ability to understand and process information) for daily decision making. The MDS indicated Resident 17 was dependent (helper did all the effort, resident did none) on staff with eating, oral hygiene, toileting, shower, upper/lower body dressing, and personal hygiene. During a concurrent observation inside Resident 17's room and interview on 8/25/2026 at 11:25 am with Certified Nurse Assistant 2 (CNA 2), CNA 2 was observed moving the resident in bed alone. CNA 2 stated Resident 17 was totally dependent on staff for ADLs and bed transfers. During an interview on 8/27/2026 at 11:19 am with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 17 had contracted bilateral (both) lower extremities and required two-person assistance for ADLs, bed mobility and transfers. LVN 2 stated Resident 17 should be assisted with two people for safety and to prevent injury both to the resident and to the staff. During an interview on 8/27/2026 at 11:30 am with the Director of Nursing (DON), the DON stated dependent residents required the assistance of two or more people during ADLs to complete the activity to ensure residents were provided adequate care and for the safety of the residents. During a review of the facility's Policy and Procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, revised March 2018, the P&P indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation, interview, and record review, the facility staff failed to elevate the resident's head of the bed (HOB) for one of one sampled resident (Resident 8) receiving formula through the gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) in accordance with the resident's care plan and physician's order. This deficient practice had the potential to result in aspiration (inhalation of foreign materials) and pneumonia (a lung infection) to Resident 8. Findings: During a review of Resident 8's Face Sheet (FS), the FS indicated the facility admitted Resident 8 on 9/25/2021 and readmitted on [DATE] with diagnoses including gastroesophageal reflux disease (GERD, a disorder where stomach acid or contents leak back into the esophagus [tube that carries food and liquid from the mouth to the stomach]), encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for nutritional support), and dysphagia (difficulty in swallowing). During a review of Resident 8's untitled Care Plan (CP) initiated on 8/14/2024, the CP indicated Resident 8 was at risk for gastrointestinal distress or bleeding secondary to GERD. The care plan interventions indicated for nursing staff to keep the head of bed elevated during feeding. During a review of Resident 8's Order Summary Report (OSR) dated 5/9/2026, the OSR indicated an order for staff to elevate Resident 8's HOB at 30 to 45 degrees at all times during GT feeding for aspiration precaution. During a review of Resident 8's OSR dated 5/13/2026, the OSR indicated Resident 8 had an order for GT feeding of Glucerna 1.2 (formula) at a rate of 50 cubic centimeter (cc, unit of measurement) per hour (hr.) for 20 hours via (through) pump, to provide 1,000 cc/1200 kilo calories (kcal. - unit of energy) per day. During a review of Resident 8's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/4/2026, the MDS indicated Resident 8 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 8 was dependent (helper did all the effort) on staff for oral hygiene, toileting, shower, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 8's untitled Care Plan (CP) revised on 7/21/2026, the CP indicated Resident 8 was on GT feeding and at risk for aspiration related to dysphagia. The care plan interventions indicated for nursing staff to keep Resident 8's head of bed elevated. During a concurrent observation and interview on 8/25/2026 at 9:51 am inside Resident 8's room, Resident 8 was flat in bed with ongoing GT feeding formula running at 50 cc/hr. The Treatment Nurse (TN) stated Resident 8 was flat in bed and the head of bed should be elevated to 30 to 40 degrees to prevent aspiration. During a concurrent observation and interview on 8/25/2026 at 10:17 am inside Resident 8's room, Resident 8 was flat in bed and connected to a GT feeding formula running at 50 cc/hr. The Infection Prevention Nurse stated Resident 8's head of bed should have been elevated to 30 to 45 degrees to prevent aspiration. During an interview on 8/27/2026 at 3:42 pm with the facility's Director of Nursing (DON), the DON stated residents receiving GT feeding needed the head of bed (HOB) elevated and not lying flat in bed to prevent aspiration. During a review of the facility's Policy and Procedure (P&P) titled Enteral Feeding, revised 11/2018, the P&P indicated Adequate nutritional support through enteral nutrition is provided to residents as ordered. The provider will consider the need for supplemental orders, including head of bed elevation.

Based on interview and record review, the facility failed to ensure one of three sampled residents' (Resident 1's) medical record was complete and accurately documented when:1. Licensed Vocational Nurse (LVN) 3 did not document the time LVN 3 found Resident 1 had a change of condition regarding the edema (swelling caused by fluid trapped in the body's tissues) on extremities bilaterally and the time LVN 3 notify the physician and Resident 1's Family Member (FM) on [DATE].2. LVN 6 and Registered Nurse (RN) 1 did not document whether facility staff initiated the CPR (Cardiopulmonary Resuscitation- is an emergency lifesaving procedure performed when the heart stops beating) on Resident 1, the initiated time for CPR, and the time facility staff called the 911 (emergency number to request the services of the police, fire department, paramedics, ambulance) on [DATE].These deficient practices resulted in incomplete and inaccurate documentation in Resident 1's medical record and had the potential for delaying interventions and services for Resident 1.Findings:During a review of Resident 1's Face Sheet (FS- front page of the chart that contains a summary of basic information about the resident), the FS indicated the facility originally admitted Resident 1 on [DATE] and readmitted on [DATE] with diagnoses which included acute respiratory failure (a life-threatening medical emergency when not enough oxygen passes from lungs to blood), heart failure (when the heart is not pumping as well as it should), and sepsis (a life-threatening blood infection).During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated [DATE], the H&P indicated Resident 1 does not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 1 had severely impaired cognition (ability to make daily decisions). The MDS indicated that Resident 1 was dependent on staff (helper does all the effort to complete the activity) for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Licensed Nurses Note form (LNN) created by LVN 3, dated [DATE], type as Change of Condition Note, the LNN indicated Resident 1 was observed with edema to bilateral upper and lower extremities and the primary physician and family member were notified. The LNN indicated that there was no time documented about the resident's change of condition and the primary physician and family member were notified.During a review of Resident 1's Progress Notes (PN) created by Registered Nurse (RN) 1, dated [DATE] and timed at 7 PM, the PN indicated on [DATE], Resident 1 was found unresponsive when RN 1 and paramedics (healthcare professional who responds to emergencies and provide medical care to patients both on the scene and on their way to a nearby hospital or medical facility) entered Resident 1's room. The PN indicated that there is no time when 911 was called. The PN indicated that there is no time and person who initiated the CPR for Resident 1.During a review of Resident 1's Progress Notes (PN) created by Licensed Vocational Nurse (LVN) 6, dated [DATE] and timed at 10:43 PM, the PN indicated on [DATE], Resident 1 was found unresponsive and the Responsible Party/FM (RP) requested to call 911 and start CPR for Resident 1. The PN indicated that there is no time when 911 was called. The PN indicated that there are no time and person who initiated the CPR for Resident 1.During a review of Resident 1's medical records on [DATE], the medical records indicated that there is no document that indicated the time facility staff found Resident 1 had edema on Resident 1's extremities and the time facility staff notified the physician and Family Member. Resident 1's medical records indicated that there is no document that indicated the time 911 was called and the time and the person who initiated CPR for Resident 1.During a concurrent interview and record review on [DATE] at 12:15 PM with LVN 3, Resident 1's Licensed Nurses Note (LNN), dated [DATE], was reviewed. LVN 3 stated that the LNN did not indicate the time when the change of condition regarding the edema on bilateral extremities occurred and the time when facility staff notify the physician and Resident 1's Family Member about Resident 1's change of condition. LVN 3 stated that the LNN did not indicate LVN 3 endorse the change of condition to the next shift nurses. LVN 3 stated that the LNN is incomplete and inaccurate and staff should document the time of Resident 1's change of condition, the time of staff notifying the physician, and endorse to the following shift nurse.During a phone interview on [DATE] at 2:07 PM with RN 1, RN 1 stated RN 1 did not get endorse from the previous shift nurse and did not know the change of condition regarding Resident 1's edema on Resident 1's bilaterally extremities on [DATE]. RN 1 stated the nursing staff should endorse and document any change of conditions. RN 1 stated CPR was initiated on Resident 1 and continued by the paramedics on [DATE], but RN 1 did not know the exact time facility staff initiated the CPR and did not document the time when the CPR was initiated and continued by the paramedics. RN 1 stated that the nursing staff should document the time and process of the CPR on Resident 1.During an interview on [DATE] at 3:15 PM with LVN 5, LVN 5 stated LVN 5 initiated and provided CPR to Resident 1 on [DATE], but LVN 5 did not document any notes regarding the incident for Resident 1. LVN 5 stated that nursing staff (other staff) should document the process while LVN 5 was performing CPR on Resident 1.During a phone interview on [DATE] at 11:41 AM with LVN 6, LVN 6 stated LVN 6 got endorse from LVN 3 that Resident 1 was found having edema on both arms in the morning shift (from 7am to 3pm) on [DATE]. LVN 6 stated LVN 6 did not document when the CPR was initiated on Resident 1 on [DATE]. LVN 6 stated that nursing staff should document any change of condition such as edema and the process of CPR completely and accurately.During a concurrent interview and record review on [DATE] at 3:30 PM with the Director of Nursing (DON), Resident 1's LNN, dated [DATE], and Progress Notes (PN), dated [DATE], were reviewed. The DON stated Resident 1's LNN and PN are incomplete and inaccurate. The DON stated it was important to complete the documentation accurately to reflect the care provided.During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, revised 7/2017, the P&P indicated, All services provided to the resident progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the inter disciplinary [NAME] regarding the resident's condition and response to care. The P&P indicated, Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. The P&P indicated, Documentation of procedures and treatments will include care-specific details, including the date and time the procedure/treatment was provided.

Based on interview and record review, the facility failed to protect the resident's right to be free from sexual abuse and follow its policy and procedure (P&P) titled Abuse & Mistreatment of Resident, for one of three sampled residents (Resident 1) when on 6/8/2026, Resident 1 reported Certified Nursing Assistant 1 (CNA 1) sexually abused Resident 1. This failure resulted in Resident 1 subjected to sexual abuse by CNA 1 while under the care of the facility. Resident 1 refused to eat breakfast and lunch on 6/8/2026 and Resident 1 cried and did not want CNA 1 to be assigned to Resident 1. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) for a sexual assault response team (SART, a group of trained professionals who comes together to support people after a report of sexual harm) assessment. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 11/28/2016 and readmitted on [DATE] with diagnoses including cerebral infarction (brain damage), psychotic disorder (when the resident lost touch with reality), major depressive disorder (long lasting sadness and a loss of interest in normal activities) and anxiety disorder (a mental health condition where a person experienced intense, ongoing fear and worry about everyday situations). During a review of Resident 1's History and Physical (H&P) dated 10/26/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 4/19/2026, the MDS indicated Resident 1 had intact cognition (ability to think and reason). The MDS indicated Resident 1 had severely impaired vision (no vision, eyes did not appear to follow objects). The MDS indicated Resident 1 required supervision from staff with eating and oral hygiene. The MDS indicated Resident 1 required moderate assistance (helper did less than half the effort) from staff with bed-to-chair transferring. The MDS indicated Resident 1 required maximal assistance (helper did more than half the effort) from staff with toileting hygiene, showering/ bathing, and personal hygiene. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there was a change of condition among the residents) form, dated 6/8/2026, the SBAR indicated on 6/8/2026 at 8:06 a.m., Resident 1 alleged CNA 1 got on top of Resident 1, kissed Resident 1's mouth, touched Resident 1's right breast, masturbated, and finished masturbation on top of Resident 1 on 6/8/2026. The SBAR indicated Resident 1 was crying and refused to eat breakfast and lunch. The SBAR indicated the facility transferred Resident 1 to GACH 1 for a SART assessment. During a review of Resident 1's Physician Order (PO) dated 6/8/2026, the PO indicated Resident 1 had an active order to transfer to GACH 1 related to alleged sexual abuse. During a review of Resident 1's GACH 1 H&P dated 6/8/2026, the GACH 1 H&P indicated Resident 1 arrived at GACH 1 following a report of sexual assault (any unwanted sexual contact or activity that happened without clear, voluntary consent) on 6/8/2026. The GACH 1 H&P indicated Resident 1 stated CNA 1 masturbated on Resident 1 while changing Resident 1's adult brief on 6/8/2026. During an interview on 6/8/2026 at 11:45 a.m. with Resident 1, Resident 1 stated, on 6/8/2026 after 12 a.m., Resident 1 used the call light to call CNA 1 for adult brief change. Resident 1 stated CNA 1 closed the door and started kissing Resident 1 on the lips. Resident 1 stated CNA 1 tried to put CNA 1's tongue into Resident 1's mouth, and Resident 1 kept Resident 1's mouth shut. Resident 1 stated Resident 1 felt CNA 1's hand squeezing on Resident 1's right breast. Resident 1 stated Resident 1 was blind, and all Resident 1 could see was black. Resident 1 stated Resident 1 could hear and feel without any sensational impairment. Resident 1 stated CNA 1 touched Resident 1's right groin and tried to put fingers inside Resident 1's vaginal area. Resident 1 stated Resident 1 kept Resident 1's legs closed. Resident 1 stated CNA 1 kissed Resident 1's groin area. Resident 1 stated CNA 1 was standing next to Resident 1's bedside. Resident 1 stated CNA 1 grabbed Resident 1's left hand to touch CNA 1's penis and buttock area. Resident 1 stated Resident 1 felt CNA 1's chest on Resident 1. Resident 1 stated Resident 1 was frozen and unable to move or say anything when CNA 1 was on top of Resident 1. Resident 1 stated CNA 1 used a towel to clean up the warm and wet stuff on Resident 1's groin area. Resident 1 stated it was approximately 15 minutes that CNA 1 stayed in Resident 1's room. Resident 1 stated CNA 1 stated I am done. I see you in the morning. Resident 1 stated CNA 1 did not return to Resident 1's room for the rest of the shift. Resident 1 stated Resident 1 did not want adult brief change at 5:30 a.m. by CNA 1 so Resident 1 did not call for diaper (adult brief) change. Resident 1 stated Resident 1 did not tell the night shift staff because Resident 1 wanted to wait for the morning social workers. Resident 1 stated Resident 1 did not eat breakfast the morning after the incident on 6/8/2026. During an interview on 6/8/2026 at 1:07 p.m. with CNA 4, CNA 4 stated Resident 1 told CNA 4 that CNA 1 got on top of Resident 1 on 6/8/2026. CNA 4 stated Resident 1 said Resident 1 felt semen on Resident 1's upper body and abdomen. CNA 4 stated Resident 1's allegation was considered as sexual abuse/assault. During an interview on 6/8/2026 at 1:17 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated, on 6/8/2026 around 8 a.m., Resident 1 was crying inside Resident 1's room and stated Resident 1 did not want the charge nurse to assign CNA 1 to Resident 1 again. LVN 1 stated Resident 1 told LVN 1 that CNA 1 touched Resident 1. During an attempted telephone interview with CNA 1 on 6/8/2026 at 1:20 p.m. CNA 1 did not pick up the phone call from Surveyor 1. Surveyor 1 left a voice message to CNA 1 on 6/8/2026 at 1:20 p.m. During a concurrent interview and surveillance video review on 6/8/2026 at 1:34 p.m. with the administrator (ADM), the ADM stated the video indicated CNA 1 entered Resident 1's room with the door open on 6/8/2026 at 1:14 a.m. The ADM stated the video indicated CNA 1 helped Resident 1 to locate the television remote control. The video indicated CNA 1 entered Resident 1's room and placed clean linen on Resident 1's bedside table on 6/8/2026 at 1:16:22 a.m. and closed Resident 1's door on 6/8/2026 at 1:17:11 a.m. The video indicated CNA 3 walked past by Resident 1's closed door on 6/8/2026 at 1:28:53 a.m. The video indicated CNA 1 left Resident 1's room and closed the door on 6/8/2026 at 1:31:32 a.m. The ADM stated CNA 1 left Resident 1's room carrying dirty linen. The ADM stated the facility suspended CNA 1 during the investigation. During a review of CNA 1's text message to Surveyor 1 on 6/8/2026 at 2:20 p.m., the text message indicated CNA 1 did not want to talk to anyone and refused to talk on the phone. During an interview on 6/9/2026 at 11:09 a.m. with the Director of Nursing (DON), the DON stated on 6/8/2026, Registered Nurse 1 (RN 1) called the DON and informed the DON that Resident 1 stated CNA 1 masturbated on top of Resident 1 on 6/8/2026. The DON stated Resident 1 was seen by the SART team in GACH 1 on 6/8/2026. The DON stated the DON was unable to interview CNA 1. During a review of the facility's undated P&P titled, Abuse & Mistreatment of Resident, undated, the P&P indicated the facility should uphold a resident's right to be free from sexual abuse. The P&P indicated that sexual abuse included assault and battery (the touching of another person's intimate parts without their consent, or against their will).

Based on observation, interview and record review, the facility failed to treat residents with dignity and respect for three out of three sampled residents (Resident 1, 2, and 3) when: 1. Resident 1 was not notified about not attending adult day care center (a community-based facility providing supervised, structured, and non-residential care for adults with physical or cognitive impairments) and was not given a reason why she did not attend. 2. Resident 2 and Resident 3's bed were temporarily relocated to the hallway and were not provided any privacy. These deficient practices had the potential to cause psychosocial harm, loss of dignity and respect, and feelings of frustration for Resident 1, 2, and 3. Findings:1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included systolic congestive heart failure (chronic condition, the heart does not pump blood as well as it should, occurs if the heart cannot pump [systolic] adequately and diabetes mellitus (body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism elevated levels of glucose in the blood and urine). During a review of Resident 1's History and Physical Examination (H&P, physician's clinical evaluation and examination of the resident), dated 12/1/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/25/2026, the MDS indicated Resident 1's cognitive skills (reasoning, learning, and problem-solving) for daily decision making was moderately impaired. The MDS indicated Resident 1 required set up assistance for eating. Then MDS indicated Resident 1 required supervision for oral hygiene. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) for upper body dressing and personal hygiene. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) for lower body dressing, shower/bathing, toileting hygiene and putting on/off footwear. During a review of Resident 1's Order Summary Report, dated 4/1/2026, Order Summary Report indicated Resident 1 had an order to attend adult day care center (a community-based facility providing supervised, structured, and non-residential care for adults with physical or cognitive impairments) every Monday and Tuesday. During an interview on 4/8/2026 at 10:29 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 was supposed to be picked up and taken to adult day care center but Resident 1 was never picked up. CNA 1 stated Resident 1 was dressed and ready to go to the adult day care center and no one had notified her that she was not going. CNA 1 stated Resident 1 questioned her if Resident 1 was going to the adult day care center and she told Resident 1 she did not know. CNA 1 stated she asked her charge nurse if Resident 1 was going to the adult day care center and the charge nurse stated she did not know. CNA 1 stated no one had notified Resident 1 about not going to the adult day care center and Resident 1 was looking forward to going to the adult day care center. During an interview on 4/8/2026 at 11:00 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 4/7/2026 Resident 1 was not picked up to go to adult day care center. LVN 1 stated resident was not notified why Resident 1 was not picked up because nursing staff did not know why Resident 1 was not picked up. LVN 1 stated she was supposed to notify Resident 1 and RP 1 about Resident 1 not attending the adult day care center but she did not. During an interview on 4/8/2026 at 1:45 p.m. with Resident 1, Resident 1 stated Resident 1 did not attend adult day care yesterday (4/7/2026) and nursing staff did not notify Resident 1 why Resident 1 was not picked up. Resident 1 stated Resident 1 was looking forward to attending adult day care. During an interview on 4/8/2026 at 2:05 p.m. with Resident 1's Responsible Party (RP) 1, RP 1 stated Resident 1 informed her Resident 1 was not picked up to go to the adult day care center. RP 1 stated Resident 1 was disappointed because Resident 1 wanted to go to the adult day care center and Resident 1 was looking forward to going. RP 1 stated Resident 1 did not know why Resident 1 did not go to the adult day are center and Resident 1 had asked staff but they did not give Resident 1 a reason why Resident 1 was not picked up. 2. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included atrial fibrillation heart's upper chambers (atria) beat out of coordination with the lower chambers (ventricles), can lead to blood clots in the heart) and pneumonia (lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid). During a review of Resident 2's H&P, dated 12/6/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was intact. The MDS indicated Resident 2 required set up assistance for eating. Then MDS indicated Resident 2 required supervision for oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 2 required moderate assistance for lower body dressing, shower/bathing, toileting hygiene and putting on/off footwear. 3. During a review of Resident 3's AR, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included overactive bladder (a sudden, uncontrollable urge to urinate, often leading to frequent bathroom trips) and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). During a review of Resident 3's H&P, dated 11/15/2025, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 3 required set up assistance for eating. Then MDS indicated Resident 3 required supervision for oral hygiene and upper body dressing. The MDS indicated Resident 3 required moderate assistance for toileting hygiene, lower body dressing, shower/bathing, toileting hygiene and putting on/off footwear. During an observation on 4/7/2026 at 8:28 a.m. in the hallway, the screen dividers were used to corner off two resident beds. The screen dividers did not prevent visualization of one resident in bed. Resident 3 was in bed. During an observation on 4/7/2026 at 3:35 p.m., in the hallway, staff remove screen dividers and push Resident 3's bed back to Resident 3's room. During an interview on 4/8/2026 at 9:20 a.m. with Maintenance Director (MD), the MD stated Resident 2 and Resident 3 were temporarily relocated to the hallway because Resident 2 and 3's room required repair. The MD stated residents always got relocated to the hallway when their room got repaired. MD stated facility provided screen dividers for privacy for the residents. The MD stated the screen dividers did have a small gap where you can visualize behind the screen divider. During an interview on 4/8/2026 at 10:18 a.m. with CNA 1, CNA 1 stated Resident 2 and Resident 3 were relocated to the hallway, where it was semiprivate and were separated by small curtains. CNA 1 stated when residents got relocated to the hallway, residents did not get a television. CNA 1 stated she did not think placing residents in the hallway offered residents respect and dignity because residents would not feel comfortable being in the hallway and would feel like other residents and staff were watching them. CNA 1 stated Resident 2 refused to take a shower because Resident 2 did not want to get undressed because Resident 2 did not want anyone to see Resident 2 undressed. CNA 1 stated Resident 2 preferred to take a shower when Resident 2 returned to Resident 2's room because there was privacy there and could get undressed there. During an interview on 4/8/2026 at 11:13 a.m. with LVN 1, LVN 1 stated when residents get relocated to the hallway, a curtain divider is provided for privacy. LVN 1 stated if residents had a conversation, everyone in the hallway would hear their conversation and that was not providing privacy to residents. LVN 1 stated she did not ask residents how they felt or if they had any concerns about being relocated to the hallway. LVN 1 stated it was important to follow up with residents to see how they are feeling because it was nursing staff's job to make residents comfortable and safe. During an interview on 4/8/2026 at 1:12 p.m. with Registered Nurse (RN) 1, RN 1 stated nursing staff should have checked if there were vacant beds before relocating residents to the hallway. RN 1 stated the relocation area did not provide safety to residents because there were no walls to prevent residents from falling. RN 1stated nursing staff should have received consent from residents prior to relocating residents. During an interview on 4/8/2026 at 1:29 p.m. with Resident 2, Resident 2 stated on 4/7/2026 Resident 2 was relocated to the hallway because Resident 2's room needed to be repaired. Resident 2 stated that morning (4/7/2026) Resident 2 was informed about the move and was not given a choice if Resident 2 wanted to move. Resident 2 stated Resident 2 did not like the relocation area because it had no privacy. Resident 2 stated Resident 2 did not feel safe in that area because Resident 2 wanted Resident 2's bed against the wall. Resident 2 stated Resident 2 did not want to be relocated to that area again because it had no privacy and felt weird that other residents could see Resident 2 get undressed. During an interview on 4/8/2026 at 2:52 p.m. with Director of Nursing (DON) the DON stated relocated residents were given privacy curtains and the area lacked full privacy and the privacy curtains used had gaps. The DON stated she did not know if the privacy curtain provided enough privacy or not. The DON stated she was not aware of who got consent from resident to be relocated to the hallway. The DON stated it was not an acceptable practice to place residents in the hallway because it did not provide dignity or respect to residents. The DON stated residents required dignity and respect for their self-esteem and morale. The DON stated it was important to provide dignity and respect to residents because it was a basic need and a human right. During a review of facility's Policy and Procedure (P&P), titled Resident Rights, dated 2/2021, the P&P indicated employees shall treat all residents with kindness, respect, and dignity. The P&P indicated federal and state laws guarantee certain basic rights to all residents of this facility. The rights include the resident's right to be informed of, and participate in, his or her care planning and treatment. During a review of facility's P&P titled Dignity, dated 2/2021, the P&P indicated each resident would be cared for in a manner that promoted and enhanced his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated staff would inform and orient residents to their environment and procedures would be explained before they are performed and residents will be told in advance if they are going to be taken out of their usual or familiar surroundings.

Based on interview, and record review, the facility failed to develop a care plan (a document that outlines a person's health needs and the care they require) for one of two sampled residents (Resident 1) when: 1. Facility did not ensure Resident 1 had a care plan for attending activities outside the facility. This deficient practice had the potential to negatively affect Resident 1's mental and psychosocial well-being. Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included systolic congestive heart failure (chronic condition, the heart does not pump blood as well as it should, occurs if the heart cannot pump [systolic] adequately and diabetes mellitus (body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism elevated levels of glucose in the blood and urine). During a review of Resident 1's History and Physical Examination (H&P, physician's clinical evaluation and examination of the resident), dated 12/1/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/25/2026, the MDS indicated Resident 1's cognitive skills (reasoning, learning, and problem-solving) for daily decision making was moderately impaired. The MDS indicated Resident 1 required set up assistance for eating. Then MDS indicated Resident 1 required supervision for oral hygiene. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) for upper body dressing and personal hygiene. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) for lower body dressing, shower/bathing, toileting hygiene and putting on/off footwear. During a review of Resident 1's Order Summary Report, dated 4/1/2026, Order Summary Report indicated Resident 1 had an order to attend adult day care center (a community-based facility providing supervised, structured, and non-residential care for adults with physical or cognitive impairments) every Monday and Tuesday. During a review of Resident 1's electronic medical record, unable to locate Resident 1's care plan indicating Resident 1 was to attend adult day care center on Monday's and Tuesdays. During an interview on 4/8/2026 at 2:52 p.m. with Director of Nursing (DON), the DON stated a care plan was a blueprint of care that would be provided to a resident. The DON stated if something did not get care nursing staff would not know what interventions to follow. The DON stated it was important to develop care plans so all nursing staff have the same approach in care. The DON stated Resident 1 should have a care plan for attending adult day care because that was part of Resident 1's activities. The DON stated the care plan for adult day care should indicate days of attendance, transport arrangements, and assisting resident in preparation. The DON stated if there was no care plan for attending adult day care, it will not be done and it would not be consistent. During a review of facility's Policy and Procedure (P&P) titled Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs would be developed and implemented for each resident. The P&P indicated the comprehensive, person-centered care plan would describe the services that would be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) and Social Services Director (SSD), properly wore N95 (a highly protective tight-fitting mask that filters harmful germs and requires a fit test to work properly) respirator/mask in accordance with infection control standards. This deficient practice had the potential to result in residents and staff being at increased risk of infection due to inadequate adherence to infection control procedures.On March 3, 2026, at 2:15 p.m., an unannounced complaint visit was conducted at the facility regarding an infection control. During an interview with LVN 1 on 3/3/2026 at 3:38 p.m., LVN 1 was observed wearing an N95 respirator that did not have a tight seal to the face due to facial hair. LVN 1 stated that he had attended an in-service in February 2026 on Infection Control Prevention and Management: COVID 19 (an infectious disease caused by the SARS-Cov-2 virus) - Proper Use of PPEs (Personal Protective Equipment, clothing or equipment that keeps healthcare workers and residents safe from germs or harmful substances), Handwashing, N95 Donning and Doffing. During an observation on 3/3/2026 at 4:55 p.m., near Nursing Station 1, observed the SSD removed his N95 respirator and placed the respirator in the trash. SSD was observed placing a new N95 respirator on his face; however, a complete seal was not achieved due to facial hair. The N95 respirator rested on top of facial hair and did not provide a tight seal to the face. During an observation and interview on 3/3/2026 at 4:55 p.m., IP stated that she had not considered that the N95 mask would not allow for a complete seal when asked about SSD's beard. IP acknowledged that the N95 mask would not provide any protection to the staff member due to the incomplete facial seal. During an interview on 3/3/2026 at 4:55 p.m., the DON was informed that SSD and LVN 1 both have beards and were improperly wearing the N95 mask. The DON stated that all staff members were instructed to check the N95 mask for a proper seal by checking for any air leaks at the bridge of the nose. The DON stated that she would in-service both staff members immediately on the proper wearing of the N95 mask. During a review of the facility's undated policy and procedure (P&P), titled Infection Prevention and Control Program, the P&P indicated:1.Policy Statement: An infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections.2. Prevention of Infection: Important facets of infection prevention include educating staff and ensuring that they adhere to proper techniques and procedures.3. Monitoring Employee Health and Safety: The facility provides personal protective equipment and checks for its proper use.

Based on interview and record review, the facility failed to provide a copy of the medical records upon written request for one of three sampled residents (Resident 1).This deficient practice violated Resident 1's right to obtain a copy and Resident 1's representative to obtain a copy of Resident 1's medical records.Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness in the arm, leg, and face on one side of the body) following cerebral infarction (damage to tissues in the brain which occurs because of disrupted blood flow to the brain). During a review of Resident 1's Discharge summary, dated [DATE], the summary indicated Resident 1 was discharged on 6/16/23 to Facility #2 at the request of Resident 1's family, so Resident would be closer to home. The summary indicated the final diagnoses during the stay were altered level of consciousness (ALOC- a change in a person's mental state, affecting their awareness, alertness, and responsiveness to their environment), hypertension (high blood pressure), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and stroke (damage to the brain from interruption of its blood supply). During a review of the e-mail from the complainant, dated 8/19/25, the complainant stated the Medical Records Director (MRD) was personally served a medical records request for Resident 1's medical records on 7/31/25. During an interview on 8/19/25 at 9:38 a.m. with the Medical Records Director (MRD), the MRD stated once the requester completes the medical records request form, the facility has 24 to 48 hours to provide records. During an interview on 8/19/25 at 2:52 p.m. with the MRD, the MRD stated the medical records log sheet only tracked the resident and family medical records requests. MRD stated hospital requests for records are faxed to the facility and do not appear on the log. MRD stated attorney letters requesting medical records are sent to the facility's attorney's office for review before the release of information. MRD stated the facility has a week to process the request. MRD stated once the facility's attorney gives the approval to release the information, then the facility also checks with the Director of Nursing (DON) before the final release of the information. During an interview on 8/20/25 at 4:26 p.m. with the MRD, the MRD stated the MRD received the medical records request for Resident 1's medical records from [name of legal services] on 7/31/25 and the MRD sent the medical records request the MRD received from [name of legal services company] to the facility's attorney for review on 8/5/25. During an interview on 8/20/25 at 4:50 p.m. with the complainant, the complainant stated as of 8/20/25, the complainant has not received any of Resident 1's records from the facility. During a review of the facility's current Policy & Procedure (P&P) titled, Release of Information, revised November 2009, the P&P indicated All information contained in the resident's medical record is confidential and may only be released by the written consent of the resident or his/her legal representative (sponsor), consistent with state laws and regulations; A resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight (48) hour (excluding weekends and holidays) advance notice of such request. During a review of the facility's current Policy & Procedure (P&P) titled, Resident Rights, revised February 2021, the P&P indicated Policy Interpretation and Implementation: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to appoint a legal representative, in accordance with state law; access to personal and medical records pertaining to him or herself.

Based on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Resident 2, Resident 38 and Resident 83) medications were properly labeled and stored in accordance with the current accepted professional standards of practice.a. Resident 2's bottle of Gabapentin (an anticonvulsant medication used for nerve pain and seizures) stored in the refrigerator was not labeled with the residents' identifying information, drug information, or drug instructions. b. Resident 38's package of Sinemet (Carbidopa- Levodopa, used to treat tremors, stiffness and slow movement) medication was not removed from the medication cart once it had expired; andc. Resident 83's package of carvedilol (Coreg, used to manage heart conditions) medication was not removed from the medication cart once it had expired. These deficient practices caused an increased risk in residents receiving the wrong medication or ineffective medications leading to health complications, hospitalization or death.Findings:a. During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was readmitted to the facility on [DATE] with diagnoses including neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 2's History and Physical (H&P) dated [DATE], the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated [DATE], the MDS indicated Resident 2 had problems with short-term and long-term memory. The MDS indicated Resident 2 had limitations in movement on both sides of the upper and lower extremities (pertaining to the arms and legs).During a review of the Physician's Order Summary Report dated [DATE], the Order Summary Report indicated for Resident 2 to receive Gabapentin 2 milliliters (ml., unit of measurement) every eight hours for neuropathy. During an observation [DATE] at 7:30 a.m., inside the Station 3 medication room refrigerator, an orange clear bottle was seen with a medication label that had Resident 2's name on it, Gabapentin 250mg, and an open date of [DATE]. During a concurrent observation and interview on [DATE] at 7:50 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the medication label should have the expiration date on it, medication information including instructions, and the expiration date on it. LVN 1 stated Resident 2's bottle of Gabapentin was missing information on it because it was faded. LVN 1 stated you could not see the instructions for taking the medication, the concentration of the medication, or the expiration date. LVN 1 stated it was important to have all the information on the medication label because a nurse would not know all the information regarding the medication. b. During a review of Resident 38's Face Sheet, the Face Sheet indicated Resident 38 was admitted to the facility on [DATE] with diagnoses including Parkinsonism (a progressive disease of the nervous system marked by tremors, muscular rigidity, and slow, imprecise movements), and dementia (a progressive state of decline in mental abilities). During a review of Resident 38's H&P dated [DATE], the H&P indicated Resident 38 did not have the capacity to understand and make decisions. During a review of Resident 38's MDS dated [DATE], the MDS indicated Resident 38 had short-term and long-term memory problems and had impairments in movement on both sides of the upper and lower extremities.During a review of the Physician's Order Summary Report, the Order Summary Report indicated Resident 38 was prescribed carbidopa-levodopa 25-100mg to be given one tablet a day for Parkinson's disease.c. During a review of Resident 83's Face Sheet, the Face Sheet indicated Resident 83 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including hypertension (high blood pressure). During a review of Resident 83's H&P dated [DATE], the H&P indicated Resident 83 did not have the capacity to understand and make decisions. During a review of Resident 83's MDS dated [DATE], the MDS indicated Resident 83 had short-term and long-term memory problems and had impairments in movement on both sides of the upper and lower extremities. During a review of the Physician's Order Summary Report, the Order Summary Report indicated Resident 83 was prescribed carvedilol 12.5mg three times a day and was discontinued on [DATE]. During a concurrent observation and interview on [DATE] at 1:11 p.m. with LVN 5, the bottom of medication cart 1, in hallway 2, there was a package of carbidopa-levodopa with an expiration date of [DATE] for Resident 38 and a package of carvedilol was seen with an expiration date of [DATE] for Resident 83. LVN 5 stated Resident 38's package of carbidopa-levodopa was expired and the package of carvedilol for Resident 83 was discontinued and expired. LVN 5 stated expired and discontinued medications need to be removed from the medication cart and disposed of properly to avoid being given to someone. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, revised 11/2020, the P&P indicated drug containers that have missing, incomplete, improper or incorrect labels were returned to the pharmacy for proper labeling before storage. The P&P indicated discontinued, outdated, or deteriorated drugs were returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review, the facility failed to ensure call lights/pad sensors (a communication device used by residents in healthcare facilities to signal for assistance from nursing staff) were within reach for two of two sampled residents (Residents 46 and 32).These failures had the potential for Residents 46 and 32 not to receive necessary care or receive delayed services.Findings: a. During a review of Resident 46’s admission Record (AR), the AR indicated Resident 46 was readmitted to the facility on [DATE] with diagnoses including contracture (a stiffening/shortening at any point, that reduces the joint’s range of motion) of the right hand and elbow, quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), and history of falling. During a review of Resident 46’s Minimum Data Set (MDS, a resident assessment tool), dated 5/15/2025, the MDS indicated Resident 46 had severely impaired cognition (ability to understand and process information) and was dependent (helper did all the effort, resident did none of the effort to complete the activity) on staff with oral hygiene, toileting, shower, upper and lower body dressing and personal hygiene. During a review of Resident 46’s Care Plan (CP), dated 5/14/2025, the CP indicated Resident 46 was at risk for falls / injury related to generalized weakness, impaired cognition, impaired vision, poor balance and safety awareness / judgement. The CP interventions included keeping the pad / call light within easy reach and close to the resident. During an observation, inside Resident 46’s room on 7/22/2025 at 8:40 a.m., with the Infection Prevention Nurse (IPN), Resident 46 was in bed, and on her back with the pad sensor above and on the right upper part of the bed, next to Resident 46’s pillow. Resident 46 could move Resident 46’s left arm and hand up and down. Resident 46’s right arm and hand were contracted. During a concurrent interview, the IPN stated Resident 46 could not move her right arm and hand and could not reach the pad sensor call light. The IPN stated the pad sensor call light should be placed close or next to Resident 46’s left arm and hand for Resident 46 to use when needed. During an interview on 7/24/2025 at 10:36 a.m., the Director of Nursing (DON) stated all pad sensors and call lights should be placed on the strong arm / hand of the resident to call for assistance and for staff to address the resident’s needs timely. During a review of the facility’s policy and procedures (P&P) titled, “Call System, Resident,” dated March 2023, the P&P indicated, “Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Call system communication may be audible or visual. The system may be wired or wireless. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan.” b. During a review of Resident 32’s admission Record, the admission Record indicated Resident 32 was admitted to the facility on [DATE] with diagnoses including respiratory failure (a condition where there’s not enough oxygen or too much carbon dioxide in the body), gastro-esophageal reflux disease(GERD- stomach acids flow back up into esophagus and causes heartburn), and dysphagia (difficulty swallowing). During a review of Resident 32’s History and Physical (H&P), dated 2/6/2025, the H&P indicated Resident 32 was able to make decisions for activities of daily living. During a review of Resident 32’s Minimum Data Set (MDS- a resident assessment tool), dated 5/12/2025, the MDS indicated Resident 32 rarely had the ability to understand and was dependent (helper does all of the effort and the resident does one of the efforts to complete the activity) on staff for personal hygiene, showering, and dressing. During an observation on 7/22/2025 at 12:22 p.m., in Resident 32’ s room, Resident 32 was lying in the bed. The call light was in the bedside table drawer, and not within reach of Resident 32. During an observation on 7/22/2025 at 1:49 p.m., in Resident 32’s room, Resident 32 was lying in the bed, the call light was in the bedside table drawer, and not within reach of Resident 32. During a concurrent interview and record review on 7/23/2025 at 1 p.m. with Certified Nursing Assistant (CNA) 2, a picture of Resident 32’s call light taken on 7/22/2025 at 12:22 p.m. was reviewed. CNA 2 stated the call light should be within reach next to Resident 32. CNA 2 stated if Resident 32 needed to call for help she would not be able to call and could fall. During a concurrent interview and record review on 7/23/2025 at 1:30 p.m. with Licensed Vocational Nurse (LVN) 3, the same picture was reviewed. LVN 3 stated Resident 32’s call light was not within reach so the resident could have access if she wanted to be changed or needed assistance. During a review of the facility’s policy and procedure (P&P) titled, “Answering the Call Light,” dated 3/2023, the P&P indicated the purpose was to ensure timely responses to the resident’s requests and needs. The P&P indicated to ensure the call light was accessible to the resident when in bed or wheelchair in room.

Based on observation, interview, and record review, the facility failed ensure proper sanitation and safe handling practices in the kitchen in accordance with professional standards for food service safety. The site glass tube (transparent area that allows you to check the level of a liquid) on the coffee maker and the ice machine were both observed with brown substances.This deficient practice caused an increased risk in mold and bacteria, leading to contamination and residents having foodborne illness. Findings:a. During a concurrent observation and interview on 7/22/2025 at 8:27 a.m. with the Dietary Supervisor (DS) in the kitchen, the coffee machine site glass tube was noted to have thick, brown build-up. The DS stated the build-up could contain bacteria which could make you sick. The DS stated she did not know when the coffee machine was last cleaned and that the machine should be deep cleaned every week.b. During a concurrent observation and interview on 7/22/2025 at 8:29 a.m. with DS in the kitchen, the ice machine was noted to contain a light brown slimy substance when it was wiped with a clean towel. The DS could not state what the substance was. The DS stated the light brown slimy substance should not be there. The DS further stated the substance can contaminate the ice and make someone sick. During a review of the Dietary Supervisor's Job Description, dated January 2022, the description indicated the dietary supervisor would make sure food service equipment was clean at all times.

Based on observation, interview, and record review the facility failed to ensure one of six sampled residents (Resident 28) was free from physical abuse when Resident 78 had become anxious (experiencing worry, unease, or nervousness) and failed to monitor Resident 78's whereabouts. This deficient practice of not monitoring Resident 78's whereabouts after he felt anxious caused Resident 28 to be physically abused by Resident 78. Findings: a. During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was admitted to the facility on [DATE] with diagnoses of fracture of fourth lumbar vertebra (a break in the bone in the lower back), syncope (a temporary loss of consciousness), and osteoporosis (a weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 28's History and Physical (H&P), dated 9/8/2024 the H&P indicated, Resident 28 had the capacity to understand and make decisions. During a review of Resident 28's Minimum Data Sheet ([MDS]- a resident assessment tool), dated 6/4/2025, the MDS indicated Resident 28's cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired. The MDS indicated Resident 28 required partial/moderate assistance (helper does less than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort) for toileting hygiene, showers, and dressing. During an interview on 7/24/2025 at 1:25 p.m. with family member for Resident 28, the family member stated, I took her home (Resident 28) on 7/22/2025 for a therapeutic leave (a temporary absence of a resident from the facility), because she was crying and stressed about being hit by Resident 78. During review of Resident 28's Change of Condition (COC) Assessment, dated 7/21/2025, the COC indicated Licensed Vocational Nurse (LVN) 4, heard a noise from Resident 28's room. The COC indicated LVN 4 had observed Resident 78 had tap Resident 28 on her right shoulder and she was upset. The COC indicated a translator was paged to speak with Resident 28. During an interview on 7/24/2025 at 2:19 p.m. with Social Service Assistant/Interpreter (SSA) 1, SSA 1 stated Resident 28 spoke Mandarin, and she had translated what had happened to Resident 28. SSA 1 stated Resident 78 went into her room, he hit her right shoulder four to five times, and she yelled for the nurse. SSA 1 stated Resident 28 was upset and scared. During an interview on 7/24/2025 at 2:39 p.m. with Director of Nursing (DON), the DON stated Resident 28 was hit by Resident 78. The DON stated Resident 28 had a startled reaction when Resident 78 entered her room, she was emotional and upset. b. During a review of Resident 78's admission Record, the admission Record indicated Resident 78 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 78's diagnoses bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), schizophrenia (a mental illness that can affect thoughts, mood, and behavior), dementia (a progress state of decline in mental abilities), and anxiety (a state emotional state characterized by feelings of unease, worry, or apprehension). During a review of Resident 78's H&P, dated 7/5/2025 the H&P indicated, Resident 78 had the capacity to make needs known but could not make medical decisions. During a review of Resident 78's MDS, dated [DATE], the MDS indicated Resident 78 cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired. The MDS indicated Resident 78 required supervision or touching assistance (helper provides verbal cues for touching/steadying, contact guard assistance as resident completes activity) for toileting hygiene, personal hygiene, and dressing. The MDS indicated Resident 78 had psychiatric mood disorders of anxiety, depression (persistent feelings of sadness and a loss of interest in activities), bipolar disorder, and schizophrenia. During a concurrent observation and interview on 7/22/2025 at 4:15 p.m. with the Administrator (ADM), the facility's video footage dated 7/21/2025 at 1:53 p.m., was reviewed. The ADM stated Resident 78 walked out of his room (Room A), crossed the hallway and entered Resident 28's room (Room B) on 7/21/2025 at 1:53 p.m.,. The ADM stated Resident 78 was no longer visible after he entered Room B. The ADM stated LVN 4 walked Resident 78 back to his room at 1:54 p.m. During a review of Resident 78's COC, dated 6/24/2025, the COC indicated Resident 78 had exhibited increased anxiety and restlessness. The COC indicated Resident 78 stated I feel like I can't relax, and was pacing in the hallway and in his room. During a review of Resident 78's Medication Administration Record (MAR), dated 7/4/2025, the MAR indicated to monitor episodes of anxiety manifested by verbalization of feeling anxious and tally by hashmarks for Ativan use every shift. During a review of Resident 78's Order Summary Report, dated 7/4/2025, the Order Summary Report indicated to monitor for anxiety manifested by verbalization of feeling anxious, and tally by hashmarks. During a review of Resident 78's Order Summary Report, dated 7/21/2025, the order summary indicated on 7/21/2025 to administer Ativan (to treat anxiety) 1 milligram ([mg] - a unit of measurement) one tablet every six hours as needed for anxiety manifested by restlessness/verbalization of feeling anxious. During a review of Resident 78's COC, dated 7/21/2025, the COC indicated Resident 78 reported on 7/21/2025 at 12:20 p.m. he was feeling anxious, and the Certified Nursing Assistants (CNAs) were aware Resident 78 was having an episode of feeling anxious and to closely monitor resident. The COC indicated on 7/21/2025 at 13:55 p.m. a noise was heard by LVN 4, Resident 78 was in Resident 28's room, and LVN 4 observed Resident 78 had tapped Resident 28 on the right shoulder with his hand half open with a light touch. During a concurrent interview and record review on 7/24/2025 at 1:50 p.m. with Director of Nursing (DON), Resident 78's MAR, dated 7/4/2025 was reviewed. The MAR indicated to monitor episodes of anxiety manifested by verbalization of feeling anxious and tally by hashmarks for Ativan use every shift. The DON stated once Resident 78 had manifested the anxious behavior frequent visual checks needed to be put in place and the nurse was to mark on the MAR he was feeling anxious. The DON stated the benefit of marking the MAR and close monitoring of Resident 78 was to prevent escalation of him feeling anxious and to prevent physical abuse. During a telephone interview on 7/24/2025 at 2:00 p.m. with LVN 4, LVN 4 stated I heard screaming from Resident 28's room and Resident 78 had his hand open in the air while Resident 28 was screaming. LVN 4 stated Resident 78 had expressed he was feeling anxious on 7/21/2025 at 12:20 p.m. and Ativan was given at 1 p.m. LVN stated it was important to know Resident 78's whereabouts due to him feeling anxious to prevent him from going into another resident's room. During an interview on 7/25/2025 at 1:04 p.m. with CNA 1, CNA 1 stated Resident 78 was feeling anxious on 7/21/2025 at 12 p.m. and she was to keep a close watch on the resident. CNA 1 stated she did not report to the charge nurse when she went to attend to another resident. CAN 1 stated she should have let someone know the whereabouts of Resident 78. CNA. 1stated if she reported it could have prevented Resident 78 from entering Resident 28's room. During a telephone interview on 7/25/2025 at 1:29 p.m. with Registered Nurse (RN) 1, RN 1 stated the residents were separated and Resident 28 was crying saying Resident 78 had hit her right shoulder. RN 1 stated Resident 78 stated he hit Resident 28 with the palm of his hand, while calling himself a bad boy. RN 1 stated when Resident 78 became anxious it was important to monitor him closely to make sure he was safe and the other residents. During a review of facility's undated policy and procedure (P&P) titled, Abuse & Mistreatment of Residents, the P&P indicated to uphold a resident's right to be free from physical, verbal, sexual, mental, involuntary seclusion, neglect, and misappropriation abuse. The P&P indicated prevention guidelines to identify of residents with potential for behavior symptoms and manifestations that may lead to conflict through comprehensive assessment, care planning, and monitoring. The P&P indicated resident identified to have behavioral symptoms with a potential for conflict shall be monitored and is the responsibility of, but not limited to, direct caregivers, Charge Nurses, Nursing Supervisors, and members of the interdisciplinary team.

Based on interview and record review, the facility failed to transmit the Minimum Data Set (MDS - a resident assessment tool) to the Centers for Medicare and Medicaid Services (CMS) system for two of four sampled residents (Resident 39, and Resident 85).This deficient practice resulted in CMS not having accurate information for Resident 39 and Resident 85.Findings:a. During a review of Resident 39's Face Sheet, the Face Sheet indicated Resident 39 was originally admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (characterized by a progressive decline in mental abilities), arthritis (a disease characterized by joint pain and inflammation), and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 39's MDS, dated [DATE], the MDS indicated Resident 39 had severe cognitive impairment (problems with ability to reason, understand, or remember) and did not have limitations in movement of the upper and lower extremities (related to the arms and legs).During a review of Resident 39's History and Physical (H&P) dated 5/23/2025, the H&P indicated Resident 39 did not have the ability to understand and make medical decisions. During a review of the CMS MDS 3.0 Nursing Home (NH) Validation Report, the CMS MDS 3.0 NH Validation Report indicated Resident 39's MDS assessment was submitted late on 9/13/2024, which was more than 14 days after the completion date.b. During a review of Resident 85's Face Sheet, the Face Sheet indicated Resident 85 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), sepsis (a life-threatening blood infection), and pneumonia (an infection / inflammation in the lungs leads to the accumulation of fluid and pus in the lungs, making it difficult to breathe). During a review of Resident 85's MDS, dated [DATE], the MDS indicated Resident 85 had severe cognitive impairment, and had limitations in movement to the upper and lower extremities. During a review of Resident 85's History and Physical (H&P) dated 7/11/2025, the H&P indicated Resident 85 had the capacity to understand and make medical decisions. During a review of the CMS MDS 3.0 NH Validation Report, the CMS MDS 3.0 NH Validation Report indicated Resident 85's MDS assessment was submitted late on 3/25/2025, more than 14 days after the completion date of 2/25/2025. During an interview on 7/25/2025 at 1:38 p.m., the Minimum Data Set Coordinator (MDSC) stated the facility had 14 days after completion of the assessment to submit the MDS to CMS. The MDSC stated Resident 39 and Resident 132 was submitted late, and it was important to submit the MDS assessment to CMS in a timely manner to ensure CMS had the most up to date information for each resident. During a review of the facility's policy & procedures (P&P) titled, Resident Assessments, dated 3/2022, the P&P indicated the Resident Assessment Instrument (RAI) User's Manual, Chapter 2 provided detailed information on timing and submission of assessments, including 14 days after completion of the assessment.

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 40's) right to a clean homelike environment. Resident 40's room had peeling paint on the walls and closet.This deficient practice caused an increased risk for Resident 40's psychosocial environment and comfort in accordance with resident preferences.Findings:During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a chronic mental illness that affects a person's thinking, behavior, and perception of reality), and gastro-esophageal reflux disease([GERD]- stomach acids flow back up into esophagus and causes heartburn).During a review of Resident 40's Minimum Data Set (MDS - a resident assessment tool), dated 4/15/2025, the MDS indicated Resident 40 had severe cognitive impairment (ability to reason, remember, and make decisions), and required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs but provides more than half the effort) from staff for showering, toileting hygiene, and dressing.During a review of Resident 40's History and Physical (H&P), dated 7/8/2024, the H&P indicated Resident 40 did not have the capacity to understand and make decisions. During an observation on 7/22/2025 at 11:39 a.m., in Resident 40's room, there was paint chipping off the wall and closet door. During a concurrent interview, Resident 40 stated he had been in the facility for four months and the paint had been like this ever since. Resident 40 stated, Yes, I would want my room to be neat and clean. During a concurrent observation and interview on 7/23/2025 at 1:05 p.m. with Certified Nursing Assistant (CNA) 2, in Resident 40's room, there was chip paint on the walls and the closet. CNA 2 stated Resident 40's room should look nice. CNA 2 stated the room that did not look nice could make the resident feel sad, looking at the chip paint daily.During a concurrent observation and interview on 7/23/2025 at 1:20 p.m. with Maintenance Assistant 1, in Resident 40's room, there was chip paint on the walls and the closet. Maintenance Assistant 1 stated, I check the rooms daily and this room is not a homelike environment for Resident 40. Maintenance Assistant 1 stated Resident 40's room should be prioritized to have the room area painted and that looking at the chip paint could make Resident 40 and visitors feel mad.During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, dated 2/2021, the P&P indicated residents were provided with a safe, clean, comfortable, and homelike environment. The P&P indicated the facility staff and management maximize the characteristics of the facility that reflect a personalized, homelike setting. The P&P indicated homelike setting includes clean, sanitary, orderly environment, and inviting colors and decor.

Based on interview and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating and protect one of three sampled residents (Resident 1) from physical abuse by failing to: 1. Ensure Registered Nurse (RN) 1, who was the alleged perpetrator (the person identified in the initial report or during the investigation as the person suspected of committing an act of abuse), was placed on leave of absence (authorized absence from work for a certain period of time) and did not have contact with Resident 1 and other residents in the facility from 1/20/2024 to 2/17/2024. 2. Ensure Licensed Vocational Nurse (LVN) 1 thoroughly investigated and reported the alleged abuse to the Administrator (ADM), State Survey Agency, Law Enforcement, and Ombudsman when Resident 1's Family Member (FM 2) reported to LVN 1 that Resident 1 told FM 2 that a male staff member (RN 1) slapped Resident 1 on the face on 1/20/2024 at around 1:30 PM. These deficient practices resulted in Resident 1 feeling worried that RN 1 might slap Resident 1 again. This had the potential to result in psychological (mental or emotional) and physical harm or injury, and placed Resident 1 at risk for further abuse from RN 1. On 2/17/2024 at 7:33 PM, the California Department of Public Health (CDPH) called an Immediate Jeopardy situation (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under freedom from abuse, neglect and exploitation. The survey team notified the Assistant Director of Nurses (ADON), Minimum Data Set (MDS, a standardized assessment and care planning tool) Coordinator, and Infection Prevention (IP) Nurse of the IJ due to the facility's failure to protect Resident 1 from physical abuse by allowing RN 1 to continue to work at the facility and have contact with Resident 1 and other residents in the facility from 1/20/2024 to 2/17/2024 and failure to thoroughly investigate and report the alleged physical abuse by RN 1 as indicated in the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigation. On 2/19/2024 at 8:35 AM, the facility provided an acceptable IJ Removal Plan (interventions to correct the deficient practice) which included the following summarized actions: 1. On 2/17/2024, the DON and RN Supervisor conducted an assessment on Resident 1, noting that Resident 1 did not have any trauma related injury and Resident 1 was at her baseline condition physically and psychosocially. 2. On 2/17/2024, the RN Supervisor notified Resident 1's Primary Physician (MD 1) of the alleged abuse with no new orders. 3. On 2/17/2024, LVN 1 and RN 1 were suspended, followed by further disciplinary action based on the determination/conclusion of the investigation. 4. On 2/17/2024, the DON notified the facility Medical Director, local police department, and Ombudsman regarding the allegation of abuse. 5. On 2/18/2024, the Director of Staff Development (DSD) Assistant reviewed all employee files, all met the requirement for abuse screening and training. 6. On 2/18/2024, the DON provided one to one in-service to LVN 1 and RN 1 regarding Abuse Prevention policy. The DON educated RN 1 and LVN 1 on the following: a. Secured the resident by removing and/or separating the resident from the alleged perpetrator as indicated. b. When the suspected perpetrator was a staff member, the staff member was to be placed immediately on administrative suspension. c. Staff would immediately notify the facility abuse coordinator for any suspicion of abuse. d. The facility abuse coordinator/administrator and or/designee would report allegations of abuse immediately, but no later than two hours after forming suspicion to the state survey agency, law enforcement, and Ombudsman. 7. On 2/18/2024, the Psychiatrist conducted a virtual consultation and informed the facility that the resident did not exhibit any signs or symptoms of distress and did not require any psychotropic medications. On 2/19/2024 at 11:18 AM, while onsite, the survey team confirmed the implementation of the IJ corrective actions through interview and record review. The survey team removed the IJ in the presence of the Director of Nursing (DON) and ADM. Cross Reference F609 and F610 Findings: During a review of Resident 1's Admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on [DATE] with diagnoses that included Down Syndrome (genetic condition caused by having an extra chromosome [structures that carry genetic information] which was presented by growth, developmental, and learning delays that vary from mild to severe), contracture (fixed tightening of muscles, tendons, ligaments, or skin) of muscles, and pressure-induced deep tissue damage of the sacral (triangular shaped bone at end of the spine) region. During a review of Resident 1's History and Physical (H&P) dated 9/20/2023, the H&P indicated, Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's MDS dated [DATE], the MDS indicated, Resident 1 had moderately impaired cognitive skills (ability to think, learn, and process information). The MDS indicated, Resident 1 depended on the staff for chair/bed-to-chair transfers. During a review of Resident 1's Nursing Notes (NN) dated 1/20/2024, timed at 2:00 PM, the NN indicated, (on 1/20/2024) at around 1:30 PM, FM 2 reported to LVN 1 that Resident 1 stated a male nurse slapped Resident 1 on Resident 1's face during transfer from bed to wheelchair on 1/20/2024 (untimed). The NN indicated, Resident 1 had a female Certified Nursing Assistant (CNA, unidentified) on 1/20/2024 and no male CNAs touched Resident 1 during the 7:00 AM to 3:00 PM shift. The NN indicated, Resident 1 had no signs and symptoms of acute distress and was smiling at LVN 1 and the CNA (unidentified). During a review of the facility's Monthly (Staffing) Schedule (MS) from 1/20/2024 to 2/17/2024, the MS indicated, RN 1 continued to work at the facility on 1/20/2024, 1/22/2024, 1/23/2024, 1/27/2024, 1/29/2024, 1/30/2024, 2/3/2024, 2/5/2024, 2/6/2024, 2/10/2024, 2/12/2024, 2/13/2024, and 2/17/2024 (total of 13 days). During an interview on 2/17/2024 at 10:30 AM with Resident 1 in Resident 1's room, Resident 1 stated a tall, male staff member (RN 1) slapped Resident 1 in the face during transfer from bed to wheelchair (unable to recall date and time). Resident 1 further stated Resident 1 was worried that RN 1 might hit Resident 1 again. During an interview on 2/17/2024 at 1:50 PM with another Family Member of Resident 1 (FM 1) in Resident 1's room, FM 1 stated Resident 1 told FM 2 that a male staff member slapped Resident 1 on the face on 1/20/2024 (during the 7:00 AM to 3:00 PM shift). FM 1 stated, FM 2 reported the alleged incident to LVN 1 on 1/20/2024 (untimed), and LVN 1 stated to FM 2 that Resident 1 probably had a bad nightmare. During a concurrent interview and record review on 2/17/2024 at 2:59 PM with LVN 1, Resident 1's Nursing Note (NN) dated 1/20/2024, timed at 2:00 PM, was reviewed. LVN 1 stated Resident 1 stated RN 1 slapped Resident 1 on the face (on 1/20/2024 at around 1:30 PM). LVN 1 stated LVN 1 informed RN 1 of Resident 1's alleged physical abuse. LVN 1 stated LVN 1 and RN 1 assessed Resident 1 with no physical injuries. LVN 1 stated facility staff were required to protect Resident 1 by thoroughly investigating and reporting allegations of abuse to the ADM immediately. LVN 1 stated LVN 1 did not thoroughly investigate and report the allegation of abuse to the ADM nor sent RN 1 home. LVN 1 stated LVN 1 did not follow the facility's Abuse P&P. LVN 1 stated not reporting the alleged physical abuse and not removing the alleged abuse perpetrator (RN 1) from Resident 1 put Resident 1 at risk for the abuse to happen again. During an interview on 2/17/2024 at 4:48 PM with RN 1, RN 1 stated LVN 1 notified RN 1 of Resident 1's allegation of physical abuse. RN 1 stated RN 1 did not think Resident 1's allegation of physical abuse was legitimate (legal/lawful/allowable). RN 1 stated he did not slap Resident 1. RN 1 stated RN 1 did not report the alleged physical abuse to the ADM and did not follow the facility's Abuse P&P to protect Resident 1. During an interview on 2/17/2024 at 4:36 PM with the DON, the DON stated LVN 1, and RN 1 did not inform the DON of Resident 1's physical abuse allegation. The DON stated LVN 1 informed the ADON of the alleged physical abuse on 2/17/2024 (untimed, unable to recall the time), after the survey team identified the IJ situation. The DON stated the DON followed up with RN 1 on 2/17/2024 (untimed) and confirmed that RN 1 was aware of Resident 1's alleged physical abuse and did not report the alleged physical abuse to the DON or the ADM. The DON stated there were no other male CNAs who worked on 1/20/2024 and RN 1 was the only male nurse who worked on 1/20/2024. The DON stated the DON notified the local police department on 2/17/2024 (untimed) of the alleged physical abuse that occurred on 1/20/2024. The DON stated RN 1 did not report the incident of alleged physical abuse to the ADM and did not follow the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating. During an interview on 2/17/2024 at 5:53 PM with the ADON, the ADON stated Resident 1 had Down Syndrome, but could make some of Resident 1's needs known. The ADON stated Resident 1 was alert, awake, engaged, and knew what was going on Resident 1's environment. During a review of the facility's Nursing Staffing Assignment and Sign-In Sheet, (NSA Sign-In Sheet) dated 1/20/2024, for 7:00 AM to 3:00 PM shift, the NSA Sign-In Sheet indicated, RN 1 was the only male nurse who worked on 1/20/2024 from 7:00 AM to 3:00 PM. During a review of the facility's P&P titled, Abuse, Neglect, Exploitation of Misappropriation-Reporting and Investigation, revised in 9/2022, the P&P indicated, all reports of resident abuse were reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The P&P indicated, if resident abuse was suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The P&P indicated, immediately was defined as within two hours of an allegation involving abuse. The P&P indicated, any employee who had been accused of resident abuse was placed on leave with no resident contact until the investigation was complete.

Based on observation, interview, and record review, the facility failed to provide immediate and continuous cardiopulmonary resuscitation (CPR, emergency lifesaving procedure, consisting of a combination of chest compressions, mouth-to-mouth, or mechanical breathing [using a device to help someone breaths], performed when the heart stops beating or beats ineffectively and/or to restore breathing) to one of three sampled residents (Resident 1) who had a full code status (resident ' s heart stopped beating and/or the resident stopped breathing, the resident or their representative wishes for all lifesaving procedures to be provided to keep them alive) by failing to ensure: 1. On [DATE] at 5:45 am (as indicated in the facility video recording), Registered Nurse Supervisor 1 (RNS 1) and Certified Nursing Assistant 1 (CNA 1) did not start CPR after RNS 1 and CNA 1 found Resident 1 on the floor, in Resident 1 ' s room, unresponsive (not reacting to anything) with a weak pulse (movement of blood caused by the beating of the heart and that can be felt by touching certain parts of the body) and not breathing. 2. Licensed Vocational Nurse 1 (LVN 1), CNA 1, and CNA 2 started CPR on [DATE], after LVN 1, CNA 1, and CNA 2 put Resident 1 in bed, and found Resident 1 without a pulse and not breathing. 3. Nine of 61 CNAs (CNA 1, CNA 5, CNA 6, CNA 7, CNA 8, CNA 9, CNA 10, CNA 11, and CNA 12) and three of 35 LVNs (LVN 3, LVN 4, and LVN 5) did not have current CPR certification cards. As a result, on [DATE] at 6:30 am, Resident 1 was pronounced (noticeable or certain) dead after the Paramedics (emergency medical technicians [EMT] who provide emergency medical services) provided unsuccessful CPR to Resident 1 in Resident 1 ' s room. On [DATE] at 5:35 pm, while onsite at the facility, an Immediate Jeopardy situation (IJ, a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified. The surveyor notified the Administrator (ADM) regarding the facility ' s failure to provide immediate and continuous CPR to Resident 1 who had full code status on [DATE] at 5:45 am, and the risk for 87 other residents who were residing in the facility with full code status not receiving CPR when those residents ' hearts stopped beating and/or when they stopped breathing. The IJ was called in the presence of the facility ' s Administrator (ADM). On [DATE] at 3:47 pm, the facility submitted an acceptable Plan of Action (POA, a list of steps taken to correct the deficient practices). While onsite at the facility, the surveyor verified and confirmed the facility ' s implementations of the POA through observation, interview, and record review. The surveyor removed the IJ on [DATE] at 4:10 pm in the presence of the ADM, the Director of Nursing (DON), and the Quality Assurance Consultant (QAC). The IJ Removal Plan, dated [DATE] included the following: a. On [DATE], the DON gave in-services and educated the facility ' s staff (in general) on indications for CPR and the importance of performing CPR immediately to residents who required CPR until the paramedics took over. The in-services included: calling for assistance, activating the facility ' s emergency response system by paging Code Blue (an emergency code that used to indicate a patient/resident requiring immediate cardiopulmonary resuscitation), retrieving the emergency cart [a cart stocked with emergency medical equipment, supplies, and drugs for use by medical personnel especially during efforts to resuscitate (to revive from apparent death or from unconsciousness) a patient experiencing cardiac arrest], initiating CPR, and continuing CPR until relieved by the paramedics or when the resident (in general) demonstrated obvious signs of life. b. On [DATE], the ADM contacted a certified Basic Life Support (BLS, certified to teach adult and child CPR, automated external defibrillator [AED, delivers an electric shock through the chest to the heart when it detected an abnormal rhythm and changed the rhythm back to normal], and First Aid classes) instructor to provide CPR reeducation to nursing staff including all CNAs, LVNs, and Registered Nurses (RN)s. c. On [DATE], the facility checked CPR certification cards for all nursing staff and identified eight of 61 CNAs and three of 35 LVNs did not have current CPR certification cards. d. On [DATE], the DON and the RNS 3 identified 87 of 123 residents had full code status. e. On [DATE], the certified BLS instructor conducted CPR training to nursing staff. f. On [DATE], CNA 2, LVN 1, and RNS 1 attended the CPR training provided by the certified BLS instructor. The facility scheduled a one-to-one CPR training for CNA 1 as soon as CNA 1 was available to attend (unspecified date). g. On [DATE], after the CPR classes were completed, the facility checked CPR certification cards (successfully completion of a designated first aid course in an authorized hospital, health, or training organization) for all 110-nursing staff and identified four of 61 CNAs (CNA 1, CNA 7, CNA 10, and CNA 12) did not have a current CPR card. h. On [DATE], the four CNAs without a current CPR card, which included CNA 1, were removed from the work schedule (include the hours of a day and the days of a work week that an employee is required to work) until the CNAs attended the next CPR training scheduled on [DATE]. i. On [DATE], the Assistant Director of Nursing (ADON) and the Social Services Director (SSD) updated the code status for all 123 residents and posted the list in each medication cart (MC, used to transport medications from patient room to patient room) for easy identification of code statuses. j. The DON and/or designee will conduct Mock Codes (pretend emergency situations in which a pretend patient has no pulse and/or not breathing and had to be provided CPR) twice a year and as needed. k. The Assistant Director of Staff Development (ADSD) would check CPR certification cards for employees upon hire, yearly, and as needed to ensure employees had their current CPR cards. Any nursing staff without a current CPR certification card would be removed from the work schedule until their CPR certification cards was renewed. Cross reference F726 Findings: During a review of Resident 1 ' s Admission Record, the Admission Record indicated the facility initially admitted Resident 1 to the facility on [DATE] and readmitted Resident 1 on [DATE] with diagnoses which included end stage renal disease (ESRD, a medical condition in which a person ' s kidneys permanently stop working and can no longer clean waste products from the blood and send waste products out of the body in urine). During a review of Resident 1 ' s Physician Orders for Life-Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner, or a physician assistant which specifies what a patient ' s lifesaving treatment wishes are), dated [DATE], the POLST indicated Resident 1 had full code status and wanted all lifesaving procedures to be provided to Resident 1 if Resident 1 ' s heart stopped and/or if Resident 1 stopped breathing. During a review of Resident 1 ' s History and Physical (H&P, physician ' s clinical evaluation and examination of the resident), dated [DATE], the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], the MDS indicated Resident 1 required touching or steadying assistance with toileting, dressing and personal hygiene (includes combing hair, shaving, washing/drying face and hands). The MDS also indicated Resident 1 required partial assistance to transfer to and from bed to chair/wheelchair, and to get on and off a toilet. During a review of Resident 1 ' s EMTs run report (a standard document used by emergency medical service care providers), dated [DATE] and timed 5:59 am, the report indicated EMTs arrived at the facility on [DATE] at 6:07 am and was at Resident 1 ' s bedside to evaluate Resident 1 at 6:08 am. The report indicated the EMTs found Resident 1 in bed, unresponsive and pulseless (without a pulse), and the EMTs started CPR on Resident 1 on [DATE] at 6:10 am. The report indicated Resident 1 ' s first monitored heart rhythm (electrical activity of the heart seen on a screen) was asystole (no heartbeat) and Resident 1 remained with no heartbeat after 20 minutes of CPR. The report indicated the time of Resident 1 ' s death was [DATE] at 6:30 am. During a review of Resident 1 ' s Situation, Background, Appearance, Review (SBAR, a standardized communication tool between healthcare providers) form signed by LVN 1, dated [DATE] and timed 6:30 am, the SBAR indicated Resident 1 had a change of condition identified on [DATE] at 5:55 am. The SBAR indicated Resident fell , had a change in level of consciousness (LOC, a medical term that describes a person ' s stated of awareness, alertness, and wakefulness), and had full code status with a blood oxygen level of zero (0, healthy blood oxygen level is ,d+[DATE] millimeters of mercury [mm Hg, unit of pressure] or ,d+[DATE] percent [%, number of ratio expressed as a fraction of 100]). The SBAR indicated Resident 1 fell , had a change in level of consciousness (LOC, a medical term that describes a person ' s stated of awareness, alertness, and wakefulness), and had full code status. The SBAR indicated at 5:55 am, CNA 1 reported to RNS 1 Resident 1 was on the floor. Resident 1 was assessed by RNS 1, noted unresponsive, with initial vital signs of: blood pressure (BP, ideal BP is considered to be between ,d+[DATE] mm Hg, unit of and ,d+[DATE]mmHg) of ,d+[DATE] mmHg, pulse at 39 (normal resting heart rate is from 60 to 100 beats per minute [BPM]), blood sugar at 222 milligrams per deciliter (mg/dl - units of measurement, normal fasting blood glucose concentration are between 70 mg/dL and 100 mg/dL). The SBAR indicated RNS 1 rechecked Resident 1 ' s vital signs (heart rate/HR, respiration rate/RR and BP) and Resident 1 had no pulse or zero (0 breaths per minute, normal RR for adults at rest is 12 to 18 breaths per minute) signs of breathing noted. The SBAR indicated CPR was initiated (unspecified person), 911 (emergency number for police, fire, paramedics) was called and the paramedics arrived at 6:07 am. The SBAR indicated the paramedics took over care, however, Resident 1 was unable to be revived (restore to life or consciousness) and pronounced dead by the paramedics at 6:30 am. During a review of Resident 1 ' s Licensed Nursing Note written by RNS 1, dated [DATE] and timed 6:50 am, the Nursing Note indicated at 5:55 am, (nurse assigned to Resident 1, CNA 1) reported to supervisor (RNS 1) that resident was on the floor. The note indicated RNS 1 got to Resident 1 ' s room immediately and Resident 1 was on the floor. The note indicated RNS 1 assessed Resident 1, pat Resident 1 ' s shoulder, but Resident 1 was not responsive (state of being responsive). The note indicated Resident 1 ' s pulse can hardly be appreciated (palpable, felt by touch) by RNS 1 and rise and fall (describes the physical action of breathing) of Resident 1 ' s chest was absent. The note indicated Resident 1 ' s BP was ,d+[DATE] mm Hg, the HR was 39 BPM. The note indicated (unspecified person) started CPR, called 911, the paramedics arrived at 6:07 am and took over care. The noted indicated the paramedic started IV (intravenous line - a soft, flexible tube placed inside a vein, usually in the hand or arm, used by health care providers to give a person medicine or fluids), but unable to revive Resident 1. Resident 1 was pronounced dead at 6:30 AM and Resident 1 ' s primary care physician (PCP) 1 and Family (FAM) 1 were notified by leaving a message. During a phone interview on [DATE] at 4:20 pm with LVN 1, LVN 1 stated on [DATE], between 5 am to 6 am (unable to recall the exact time), RNS 1 told LVN 1 to go to Resident 1 ' s room. LVN 1 stated when LVN 1 got to Resident 1 ' s room, LVN 1 found Resident 1 was lying on the floor and CNA 1 was standing around inside the room and CNA 1 was not performing CPR. LVN 1 stated LVN 1 did not start CPR after LVN 1 found Resident 1 on the floor because LVN 1 left Resident 1 ' s room to ask RNS 1 what LVN 1 was supposed to do. LVN 1 stated LVN 1 went back inside Resident 1 ' s room with CNA 2, and LVN 1, CNA 1, and CNA 2 put Resident 1 back in bed. LVN 1 stated LVN 1 realized Resident 1 did not have a pulse after Resident 1 was in bed. LVN 1 stated LVN 1 started chest compressions on Resident 1 until the paramedics arrived and the EMTs told LVN 1 to stop CPR. LVN 1 stated from what LVN 1 remembered from CPR training, chest compressions had to be performed immediately once a person stopped breathing and had no pulse. During a phone interview on [DATE] at 7:19 pm with RNS 1, RNS 1 stated on [DATE] at 5:55 am, CNA 1 notified RNS 1 Resident 1 was lying on the floor. RNS 1 stated RNS 1 went to Resident 1 ' s room with CNA 1 and found Resident 1 lying on the floor. RNS 1 stated RNS 1 checked for Resident 1 ' s pulse, on Resident 1 ' s neck and wrist (press with two [2] to three [3] fingers and feel for a pulse on the side of the neck closer to the rescuer). RNS 1 stated Resident 1 ' s pulse was weak and the rise and fall (describes the physical action of breathing) of Resident 1 ' s chest was hard to notice. RNS 1 stated Resident 1 did not respond nor say anything when RNS 1 spoke to or shook Resident 1 and Resident 1 ' s eyes remained closed. RNS 1 stated RNS 1 left CNA 1 in the room with Resident 1, and RNS 1 left Resident 1 ' s room to called 911. RNS 1 stated RNS 1 called a code blue and found LVN 1 and told LVN 1 to provide CPR to Resident 1. RNS 1 stated, RNS 1 did not start CPR because Resident 1 was still warm and RNS 1 was able to feel a faint (weak) pulse. RNS 1 stated, Resident 1 was yawning (uncontrolled opening of the mouth and taking a long, deep breath of air), meaning Resident 1 was still alive. RNS 1 stated when RNS 1 went back to Resident 1 ' s room, Resident 1 was in bed and LVN 1 was performing compressions on Resident 1 ' s chest. RNS 1 stated It was important to start CPR right away to save the patient. During a phone interview on [DATE] at 9:45 am with CNA 1, CNA 1 stated when CNA 1 walked inside Resident 1 ' s room to answer Resident 1 ' s call light (device used by a resident to signal their need for assistance), on [DATE] between 5 am to 6 am (unable to recall the exact time), CNA 1 found Resident 1 sliding out of the bed. CNA 1 stated CNA 1 turned Resident 1 ' s overbed light on and when CNA 1 turned around, Resident 1 was lying on Resident 1 ' s back on the floor. CNA 1 stated Resident 1 ' s eyes were closed, and Resident 1 was unresponsive. CNA 1 stated CNA 1 left Resident 1 ' s room to get help and informed RNS 1 Resident 1 fell and was unresponsive. CNA 1 stated, when RNS 1 and CNA 1 went back into Resident 1 ' s room, RNS 1 and CNA 1 could not find Resident 1 ' s pulse and Resident 1 started gasping for air three (3) to four (4) times. CNA 1 stated neither RNS 1 nor CNA 1 started CPR on Resident 1. CNA 1 stated RNS 1 left Resident 1 ' s room to call 911 and CNA 1 left Resident 1 ' s room to get LVN 1. CNA 1 stated LVN 1, CNA 1, and CNA 2 put disposable isolation gowns (one-use gown used by health care personnel to protect the wearer from coming in contact with blood, body fluids, and other infectious material) on and put Resident 1 back to bed. CNA 1 stated Resident 1 remained unresponsive while LVN 1, CNA 1, and CNA 2 put Resident 1 to bed. CNA 1 stated once in bed, LVN 1, CNA 1, and CNA 2 did not see Resident 1 ' s chest rise and fall. CNA 1 stated LVN 1 did not start CPR as soon as Resident 1 was put back to bed. CNA 1 stated LVN 1 provided Resident 1 with two one and two compressions, (thirty [30] chest compressions, followed by two rescue breaths are considered one cycle), immediately before EMTs arrived. During a phone interview on [DATE] at 12:48 pm with CNA 2, CNA 2 stated on [DATE], between 5:30 am to 6 am, LVN 1 asked CNA 2 to help put Resident 1 in bed. CNA 2 stated once CNA 2, CNA 1, and LVN 1 put Resident 1 in bed, CNA 2, CNA 1, and LVN 1 did not see Resident 1 ' s chest rise for breaths. CNA 2 stated CNA 2 and LVN 1 checked Resident 1 ' s neck and wrist for a pulse, and CNA 2 stated CNA 2 could not find Resident 1 ' s pulse. CNA 2 stated CNA 2 did not know if LVN 1 found Resident 1 ' s pulse. CNA 2 stated LVN 1 left the room after they put Resident 1 to bed. CNA 2 stated, In CPR class, if unable to find pulse, begin chest compressions right away. CNA 2 stated CNA 2 did not start CPR. CNA 2 stated Resident 1 ' s room did not have an oxygen tank (a container with oxygen inside it, used for helping people to breathe) and neither LVN 1, CNA 1, nor CNA 2 provided Resident 1 with mouth-to-mouth resuscitation (to revive from apparent death or from unconsciousness). CNA 2 stated LVN 1 returned to Resident 1 ' s room and started CPR on Resident 1 only for a few seconds, no more than a minute. During a concurrent observation and interview on [DATE] at 2:10 pm with the ADON and the Medical Records Director (MRD), in the front office of the facility, the ADON and the MRD watched the video recording, dated [DATE] between 5:42 am to 6:09 am, from Station 1 ' s security camera (a camera used to monitor activity in Nursing Station (NS) 1 ' s hallway, hallway where Resident 1 ' s room was located). The video showed the following on [DATE]: 1. At 5:42:14 am, Resident 1 ' s call light turned on. 2. At 5:44:26 am, CNA 1 went inside Resident 1 ' s room. 3. At 5:44:46 am, CNA 1 was seen in Resident 1 ' s doorway, looking out towards the nurses ' station. 4. At 5:44:50 am, CNA 1 went inside Resident 1 ' s room. 5. At 5:45:42 am, CNA 1 walked out of Resident 1 ' s room and walked towards Nursing Station (NS) 1. 6. At 5:45:42 am, CNA 1 went back inside Resident 1 ' s room. 7. At 5:45:48 am, RNS 1 went inside Resident 1 ' s room. 8. At 5:47:41 am, RNS 1 walked out of Resident 1 ' s room and opened the Medication Cart (MC) 1 located in the hallway, against the wall to the right side of Resident 1 ' s room doorway. 9. At 5:48:24 am, RNS 1 went back inside Resident 1 ' s room. 10. At 5:49:13 am, RNS 1 walked out of Resident 1 ' s room and went to MC 1. 11. At 5:50:05 am, RNS 1 walked towards NS 1 and walked back towards Resident 1 ' s room with a blood pressure machine (device that automatically measures a person ' s blood pressure at set times and records the readings). 12. At 5:50:30 am, RNS 1 went inside Resident 1 ' s room with a BP machine. 13. At 5:52:48 am, RNS 1 walked out of Resident 1 ' s room with BP machine and went to MC 1. 14. At 5:52:56 am, CNA 1 walked out of Resident 1 ' s room and walked towards the NS 1. 15. At 5:53:25 am, RNS 1 left MC 1 and walked towards the NS 1. 16. At 5:54:39 am, LVN 1 and CNA 1 went inside Resident 1 ' s room. 17. At 5:55:52 am, LVN 1 walked out of Resident 1 ' s room and walked towards NS 1. 18. At 5:57:08 am, LVN 1 went inside Resident 1 ' s room with CNA 2. 19. At 5:58:01 am, CNA 2 walked out of Resident 1 ' s room to don (put on) a yellow disposable isolation gown. 20. At 5:58:17 am, LVN 1 walked out of Resident 1 ' s room to don a yellow disposable isolation gown. 21. At 5:58:42 am, CNA 2 went inside Resident 1 ' s room. 22. At 5:58:58 am, CNA 1 walked out of Resident 1 ' s room to don a yellow disposable isolation gown. 23. At 5:59:37 am, CNA 1 went inside Resident 1 ' s room. 24. At 5:59:40 am, LVN 1 went inside Resident 1 ' s room. 25. At 6:02:36 am, RNS 1 walked in through the front door of Station 1 which led to the front lobby. 26. At 6:02:51 am, LVN 1 walked out of Resident 1 ' s room and grabbed an item (unidentified) from MC 1. 27.At 6:02:52 am, LVN 1 went inside Resident 1 ' s room. 28. At 6:02:55 am, LVN 1 walked out of Resident 1 ' s room and went to MC 1. 29. At 6:03:23 am, RNS 1 went inside Resident 1 ' s room, walked out of Resident 1 ' s room, and stopped to talk to LVN 1 who was in front of MC 1. 30. At 6:03:53 am, RNS 1 walked toward NS 1. 31. At 6:04:09 am, LVN 1 went inside Resident 1 ' s room. 32. At 6:04:30 am, RNS 1 went inside Resident 1 ' s room. 33. At 6:05:21 am, CNA 2 walked out of Resident 1 ' s room. 34. At 6:05:25 am, RNS 1 walked out of Resident 1 ' s room with a BP machine and CNA 2 went inside Resident 1 ' s room. 35. At 6:05:31 am, RNS 1 opened MC 1. 36. At 6:05:37 am, LVN 1 walked out of Resident 1 ' s room and went to MC 1 where RNS 1 was. 37. At6:05:44 am, RNS 1 walked towards NS 1. 38. At 6:05:46 am, LVN 1 went inside Resident 1 ' s room with a BP machine. 39. At 6:05:55 am, CNA 2 walked out of Resident 1 ' s room and walked towards NS 1. 40. At 6:06:03 am, LVN 1 walked towards NS 1 then went to MC 1. 41. At 6:06:20 am, CNA 2 went inside Resident 1 ' s room. 42. At 6:07:10 am, LVN 1 walked towards NS 1. 43. At 6:07:44 am, a paramedic (EMT 1) walked through the front door of Station 1. 44. At 6:07:51 am, EMT 2 walked through the front door at Station 1. 45. At 6:08:00 am, EMT 1 went inside Resident 1 ' s room. 46. At 6:08:04 am, LVN 1 went inside Resident 1 ' s room. 47. At 6:08:06 am, EMT 2 went inside Resident 1 ' s room. 48. At 6:08:12 am, an unidentified staff seen with an emergency cart headed towards Resident 1 ' s room. 49. At 6:08:19 am, an unidentified staff went inside Resident 1 ' s room and left the emergency cart outside the room. 50. At 6:08:30 am, EMT 3 walked in through Station 1 ' s front door. 51. At 6:08:37 am, EMT 4 and EMT 5 walked in through Station 1 ' s front door. 52. At 6:09:06 am, LVN 1 walked out of Resident 1 ' s room and the video ended. During an interview on [DATE] at 4:40 pm with the DON, the DON stated the DON expected nursing staff (in general) to immediately assess an unresponsive resident and request for additional help as needed. The DON stated when Resident 1 was on the floor, unresponsive and not breathing, staff (in general) needed to provide Resident 1 with oxygen. The DON stated once Resident 1 no longer had a pulse, then CPR needed to be started right away. The DON stated once CPR started, chest compressions needed to be continued until the EMTs, or another person(s) took over. The DON stated it was important to start CPR immediately to increase a resident ' s chances of recovery. The DON stated all nursing staff were required to have a current CPR certification card. During a review of the facility ' s CPR list of nursing staff without current CPR certification cards, dated [DATE], the list indicated ten of 61 CNAs (CNA 1, CNA 5, CNA 6, CNA 7, CNA 8, CNA 9, CNA 10, CNA 12, and CNA 13) and three of 35 LVNs (LVN 3, LVN 4, and LVN 5) did not have current CPR certification cards. During a review of the facility ' s policy and procedure (P&P) titled, Emergency Procedure - Cardiopulmonary Resuscitation, dated [DATE], the P&P indicated, If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual, or there are obvious signs of irreversible death. The P&P indicated the facility will provide periodic Mock Codes (simulations of an actual cardiac arrest) for training purposes. The P&P indicated, If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: a. Instruct a staff member to activate the emergency response system (code) and call 911; b. Verify or instruct a staff member to verify the DNR or code status of the individual; c. Initiate the basic life support (BLS) sequence of events. The BLS sequence of events is referred to as ' C-A-B ' (chest compressions, airway, breathing). Chest compressions: a. Following initial assessment, begin CPR with chest compressions. Minimize interruptions in chest compressions. All rescuers trained or not, should provide chest compressions to victims of cardiac arrest. Trained rescuers should also provide ventilations (to supply oxygen to the patient's lungs). Continue with CPR/BLS until emergency medical personnel arrive. A review of the American Heart Association CRP & First Aid Emergency Cardiovascular Care website titled, Algorithms, dated 2023, the website indicated for adults, verify scene safety, check for responsiveness, shoutout for nearby help, activate emergency response system via mobile device (if appropriate), get AED and emergency equipment (or send someone to do so). The website indicated, look for no breathing or only gasping and check pulse (simultaneously) and if pulse is felt within 10 seconds with no normal breathing, then to provide rescue breathing, one (1) breath every six (6) seconds or 10 breaths per minute, check pulse every two (2) minutes and if no pulse, start CPR. The website indicated, when CPR is started, perform cycles of 30 chest compressions and two (2) breaths and use an AED as soon as it is available. The website indicated if it is determined a heart rhythm cannot be checked with an AED, resume CPR cycles until an ALS (advances life support) provider takes over or the victim starts to move. [https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/algorithms#adult]

Based on observation, record review, and interviews, the skilled nursing facility (SNF) failed to take appropriate corrective action regarding an alleged threat, that Resident 1 will come back to the facility after his discharge, to shoot and stab nursing staff. Resident 2 reported to multiple facility staff of Resident 1's threat of threatening to shoot and stab staff at the facility. There were one hundred thirty five residents in the facility at that time. The facility failed to do the following: 1. Report to the Law Enforcement. 2. Report to the Department of Public Health. 3. Have documented evidence of an investigation of Resident 1's threat. 4. Take appropriate corrective actions. This deficient practice created an environment of fear and anxiety to Resident 2 and the staff, and the potential of causing grave danger, serious injury, or death to staff, residents, or visitors if Resident 1 returned to the facility. On 10/11/16, at 2:55 p.m., an onsite visit to the facility was made to investigate an anonymous complaint to the Department of Public Health, regarding Resident 1 threatening to come back to shoot and stab nursing staff after his discharge. Findings: On 10/11/2016 at 2:55 p.m. the SNF Administrator and Director of Nursing (DON) were made aware regarding an anonymous complaint to the Department of Public Health, regarding a threat that Resident 1 was coming back to the facility to shoot and stab nursing staff after his discharge. Both the Administrator and DON stated no staff, resident, or visitor reported the threat to them. During an interview on 10/11/16 at 3:35 p.m., the Social Services Assistant (SSA) stated Resident 1 yelled and was verbally abusive to staff, being easily agitated and upset over not having his usual [MEDICATION NAME] (medication used to treat people addicted to drugs). A review of Resident 1's Admission Record indicated an admitted to the facility on [DATE] with a known history of Anxiety (mental health disorder where the person feels constant panic that interferes with their activities of daily living), Type II Diabetes (inability for the body to control normal blood sugar levels), and partial traumatic amputation of the right and left foot (surgery to remove a part of the foot, or feet, caused after an injury or trauma to the feet) for which Resident 1 was admitted to the SNF. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 7/26/16, indicated Resident 1 had no problems with hearing, speech, vision, cognition, behavior, and mood. The resident was able to move in bed, transfer, and dress with only staff oversight. According to Resident 1's 8/31/16 Interdisciplinary Team (IDT) Conference Record documented by the Social Service Assistant (SSA), Resident 1 was requesting increased pain medications while visibly mumbling and having whitish secretions at the mouth during the IDT meeting, was complaining about having a dry mouth and verbalizing a flight of ideas (a rapid flow of thought, manifested by accelerated speech with abrupt changes from topic to topic: a symptom of some mental illnesses). During this IDT meeting staff questioned Resident 1 about being on drugs and Resident 1 admitted to self-administering his personal [MEDICATION NAME] (also known as [MEDICATION NAME], a narcotic drug used to treat moderate to severe pain that can cause decreased respirations, decreased blood pressure, decreased mental alertness, drowsiness, sleepiness, strange dreams, dry mouth, and drug tolerance and drug addiction to narcotics and when combined with other narcotic medication/narcotic recreational drugs can cause serious injury or death). During the IDT meeting Resident 1 continued to exhibit flight of ideas and paranoia (an intense anxious or fearful feelings and thoughts often related to persecution, threat, or conspiracy stating he had seen a man, the boyfriend of his ex-girlfriend, climb out of the fence and pointing at him when he was buying something at the facility vending machine. During an interview on 10/11/16 at 3:35 p.m., the Social Services Assistant (SSA) stated Resident 1 yelled and was verbally abusive to staff, being easily agitated and upset over not having his usual [MEDICATION NAME] (medication used to treat people addicted to drugs). During an interview, on 10/12/16 at 9:30 a.m., Resident 2 stated on the day Resident 1 was discharged [DATE], Resident 2 was in the SNF front lobby when Resident 1 came up and waited in the front lobby for his ride. Resident 1 began talking to Resident 2 and showed Resident 2 a knife tucked away in his pants, and stated he would return back to the SNF to shoot and stab the nurses. Resident 2 also stated Resident 1 threatened to come back and steal his motorized wheelchair. Resident 2 stated after Resident 1 left the facility, he informed the front desk lobby staff receptionist immediately. Resident 2 stated after informing the receptionist he went straight over to the Administrator and informed her of what Resident 1 had said. Later that same night on 10/5/16, he stated he had informed his two certified nurse assistants (CNAs), CNA 1 and CNA 2, while they assisted him back into bed for the night. Resident 2 stated he again told two other CNAs (Resident 2 stated he could not remember the exact names of the CNAs) of Resident 1's threat a few days later. During this interview, Resident 2 stated Resident 1 made brass knuckles out of the butter-knives. Resident 2 stated many times Resident 1 looked like he was under the influence while at the facility and staff knew about all of it. While talking about Resident 1, Resident 2 was observed anxious, nervous, trembling and eyes watering. Resident 2 emphasized how worried he was for the staff here. A review of the Admission Record indicated Resident 2 was admitted to the SNF (Skilled Nursing Facility) on 1/4/2014 with a history of [DIAGNOSES REDACTED] (neurological disorder where the immune system attacks the nerves triggered by a [MEDICAL CONDITION] or bacterial infection which causes muscle weakness and eventual paralysis), [MEDICAL CONDITION] (paralysis of the torso and all four limbs), and generalized muscle weakness (full body muscle weakness). A review of Resident 2's Minimum (MDS) data set [DATE] indicated Resident 2 was alert and oriented to person, place, time, and situation with no cognitive, behavior, mood, hearing, vision, or speech problems and was totally dependent on two staff for transferring, dressing, eating, toilet use, and personal hygiene, and required a motorized wheelchair for getting around. During an interview on 10/12/16 at 8:55 a.m., with a local Police Officer and the SNF Administrator, the Police Officer stated that he had visited the SNF previously for a disturbance caused by Resident 1. He recalled Resident 1 mentioned to the officers and the staff that he was from a local motorcycle gang. On 10/12/16 at 10:50 a.m., after speaking to Resident 2, the local Police Officer was talking to the Administrator. The Police Officer told the Administrator of his investigation, that Resident 1's threat to come back to shoot and stab the nursing staff, was a credible threat. During an interview on 10/12/16 at 1:05 p.m., CNA 1 stated Resident 2 told her that Resident 1 had shown him a gun and a knife and had threatened to come back and shoot and stab the nurses and that he had informed both the Administrator and the Evening Nursing Supervisor/Registered Nurse. CNA 1 stated that Resident 2 told her that Resident 1 called him on his personal cell phone on 10/5/16 around 7 pm to reiterate that he was going to come back and shoot people in the building that night. CNA 1 stated she informed the Evening Nursing Supervisor/Registered Nurse that night on 10/5/16 around 7:00 p.m. of what Resident 2 told her. CNA 1 stated she thought that because she had informed her supervisor; and Resident 2 informed both the Administrator and the Evening Nursing Supervisor/Registered Nurse, that it was being taken care of. CNA 1 stated she was very worried about this. CNA 1 stated Resident 1had been previously found making two brass knuckles from butter-knives and the Evening Nursing Supervisor/Registered Nurse was aware. During an interview with CNA 2 on 10/12/16 at 3:43 p.m. she stated she was informed by Resident 2 that Resident 1 was going to shoot and stab a few of the staff. CNA 2 stated Resident 1 was very violent, had very bad looking friends, was tall and big, full of tattoos and scary looking. CNA2 stated she was very worried about this. She stated she wouldn't put it past Resident 1 doing something like this. CNA 2 stated she had informed the Evening Nursing Supervisor/Registered Nurse the day Resident 1 was discharged but had not received follow up from him yet. During an interview with CNA 3 on 10/12/16 at 4:08 p.m. he stated Resident 2 told him that on the day that Resident 1 was discharged , Resident 1 came up to Resident 2 in the front lobby and showed him his gun and knife and said he was going to come back and shoot and stab a few CNAs. Then, two days later Resident 2 told CNA 3 that Resident 1 had called Resident 2 and told Resident 2, he was planning on coming back to shoot and stab a few of the CNAs. In an interview with the DON on 10/12/16 at 4:37 p.m. she stated staff are expected to report any resident threatening to shoot or stab nurses to the Administrator, me (DON), or higher level staff so we investigate it, call it to the police, and report it to the Department of Public Health. The DON said this did not happen and that there was no report made to the Police Department or to the Department of Public Health. On 10/14/16 at 3:30 p.m. a concurrent interview with the Administrator and the viewing of the video surveillance footage of the front lobby for 10/5/16 from 6:20 p.m. to 6:41 p.m., Resident 2 was seen sitting in his wheelchair at 6:20 p.m. talking to another resident when he was approached by Resident 1 at 6:35 p.m. and begins to talk to him, and then lifts up his white shirt to show him something, then exits the building a few minutes later at 6:40 p.m. out the front lobby door. At that time Resident 2 was seen in the video footage in his motorized wheelchair wheeling himself to the front lobby and was talking with the receptionist, then wheeled himself back into the hallway. The Administrator verified that four CNAs and one receptionist in total were made aware of Resident 2 reporting Resident 1 threatening to come back and shoot nursing staff after being discharged home. The Administrator was not able to show any evidence of an investigation, or any action taken regarding the threat. The Administrator stated the SNF had no address or valid contact phone number for Resident 1 to provide assistance to the local Police Department for this investigation. The SNF's undated Active Shooter Procedure stated staff should alert administration immediately if they believe an employee or visitor exhibits any of the following: violent behavior, unsolicited comments about violence/crimes, illegal drugs, increased/severe mood swings, increased discussions of problems at home, and unsolicited comments about dangerous weapons. According to the SNF's undated policy on Unusual Occurrences the facility was to report unusual occurrences to the local Health Department within twenty-four hours of each occurrence. The policy identified examples of unusual occurrences as occurrences that constitute an interference with facility operations that affect the welfare, safety, or health or residents, personnel or visitors, misappropriation of residents ' property by staff, and allegations of abuse, neglect.